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Lead Claims Adjuster, Hybrid

Company: MemorialCare
Location: Fountain Valley
Posted on: January 27, 2023

Job Description:


Purpose Statement / Position Summary

The Claims Lead is responsible for assisting Manager of Claims in reviewing claims processed and adjudicated by an affiliated group MemmorialCare Medical foundation(MCMF). Works closely with the Manager of Claims in developing process improvements. Responsibilities also include claim trainings and interface with health plan members and other departments. Provides limited supervision in the absence of Manager of Claims. Collaborates with other units and ensure Claims Department meets and/or exceed quality and performance standards.

This position is responsible for ensuring the integrity of the claims processing so that it is current, complete, and processed accurately as well as provides analysis to increase operational efficiency. The Claims Lead works under the supervision of the Manager of Claims to provide focused services that ensure the accuracy from the provider community through to the health plan. This position works independently as well as collaborating closely with various departments of the MemorialCare System. This is a position that needs to identify and assist with process improvement plans to improve the accuracy of the claims processing and stay current as the healthcare industry evolves.

Essential Functions and Responsibilities of the Job

  • Must be organized, understanding the workflow and regulations of claims in all lines of business;
  • Ability to lead claims team and oversee staff performance;
  • Ability to conduct claims training either in a group or individual setting;
  • Ability to comprehend and interpret documents such as provider contracts, procedure manuals, various reports, division of financial responsibility matrix;
  • Ability to deal with complex claim issues, identify claim processing deficiencies and implement effective procedure improvements;
  • Ability to handle multiple claims and system projects prioritizing deliverables;
  • Ability to work in a fast-paced environment with minimal supervision;
  • Provide support to claims phone que when needed

    Pay Range: $24.95-$36.19

    Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare-that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there's more... Check out our MemorialCare Benefits for more information about our Benefits and Rewards.



    • Minimum of three (3) years of managed care health plan claims processing experience.
    • Comprehensive knowledge of federal and state regulations pertaining to managed care, including
    • knowledge of Medi-Cal, Medicare, CPT/ICD-10 guidelines.
    • Comprehensive knowledge of regulatory requirements related to claims processing such as Title 28 and
    • Medicare Part C Claims Organization determination;
    • Comprehensive knowledge of different payment methodologies such as Medi-Cal, RBRVS, APR DRG,
    • MS DRG and other Medicare reimbursements;
    • Strong critical thinking skills and the ability to make timely, professional and ethical decisions.
    • Excellent organizational, interpersonal, communication and coaching skills.
    • Computer proficiency (MS Word, PowerPoint, and Excel)
    • Strong understanding of health care code sets including CPT, HCPCs, ICD-10 and revenue codes
    • Strong skills in MS office; including intermediate to advanced MS Excel and MS Access skills a plus
    • Strong analytical, organization and interpersonal skills
    • Knowledge of claims, payment and pricing, provider contracts, membership and enrollment a plus
    • Knowledge of Trans Union application and MHC application preferred Intermediate PC program user.
    • (MS Word, PowerPoint, Excel and Access)
    • Minimum typing speed of 45 WPM and use of Ten-Key by touch.
    • Excellent verbal, written and presentation skills


      • High school graduate or equivalent required.
      • AA, or BA/BS degree preferred.


Keywords: MemorialCare, Fountain Valley , Lead Claims Adjuster, Hybrid, Other , Fountain Valley, California

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