Verda Healthcare · 4 months ago
Claims Examiner III
Huntington Beach, CA
Contract
Onsite
Mid Level
3+ years expVerda Healthcare is committed to ensuring that underserved communities have access to health and wellness services. They are seeking a Claims Examiner III to perform advanced administrative, operational, and customer support duties within a managed care environment, focusing on the analysis and adjudication of medical claims.
Insurance
Responsibilities
Analyze and adjudicate complex medical claims in compliance with CMS guidelines and health plan policies
Review and apply appropriate fee schedules, contracts, and benefit plans
Perform claim payment reconciliations and retroactive adjustments
Identify patterns and root causes of payment discrepancies and escalate issues as needed
Respond to provider inquiries and coordinate with internal teams for resolution
Maintain documentation and track resolution outcomes
Ensure compliance with regulatory, contractual, and internal policies
Recommend process improvements based on claim trends and data analysis
Support training initiatives for new staff and peers as subject matter experts
Qualification
Required
High school diploma or GED required
Minimum of 3–5 years of experience in claims processing and adjudication, preferably within Medicare Advantage or managed care settings
Knowledge of CPT, HCPCS, ICD-10 coding, and CMS regulations
Strong analytical and problem-solving skills
Proficient in claims systems (e.g., Plexis, Facets) and Microsoft Office tools
Ability to handle confidential information in compliance with HIPAA
Strong attention to detail and accuracy
Excellent verbal and written communication
Customer service-oriented with a collaborative mindset
Ability to work independently and prioritize tasks
Commitment to continuous learning and quality improvement
Reliably commute or planning to relocate before starting work (Required)
Preferred
Associate or bachelor's degree preferred
Benefits
401(k)
Paid time off (vacation, holiday, sick leave)
Health insurance
Dental Insurance
Vision insurance
Life insurance
Company
Verda Healthcare
VERDA Healthcare is a new Medicare Advantage Plan launched by a passionate, purpose-driven group of experienced healthcare professionals committed to the idea that healthcare should be easily and equitably accessed by all.
11-50 employees
Funding
Current Stage
Early StageLeadership Team
James Kim
Board Member, Co-Founder and Interim CMO
Thinh Tran, MD, MBA
Co-Founder and Board Member
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