Claims Examiner I
Company: Astiva Health, Inc
Location: Los Angeles
Posted on: January 10, 2026
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Job Description:
Job Description About Us: Astiva Health, Inc., located in
Orange, CA is a premier healthcare provider specializing in
Medicare and HMO services. With a focus on delivering comprehensive
care tailored to the needs of our diverse community, we prioritize
accessibility, affordability, and quality in all aspects of our
services. Join us in our mission to transform healthcare delivery
and make a meaningful difference in the lives of our members.
SUMMARY: Under the direction of the Vice President of Claims, this
position is responsible for manual input and adjudication of claims
submitted to the health plan. The ideal candidate will need to
interpret and utilize capitation contracts, payor matrixes,
subscriber benefit plan, and provider contracts; as well as
resolving customer service inquiries, status calls, andclaim
tracers. ESSENTIAL DUTIES AND RESPONSIBILITIES include the
following: • Data enter paper claims into EZCAP. • Review and
interpret provider contracts to properly adjudicate claims. •
Review and interpret Division of Financial Responsibility (DOFR)
for claims processing. • Perform delegated duties in a timely and
efficient manner. • Verify eligibility and benefits as necessary to
properly apply co-pays. • Understands eligibility, enrollment, and
authorization process. • Knowledge of prompt payment guidelines for
clean and unclean claims • Process claims efficiently and maintains
acceptable quality of at least 95% on reviewed claims. • Meets
daily production standards set for the department. • Prepares
claims for medical review and signature review per processing
guidelines. • Identify the correctly received date on claims, with
knowledge of all time frames for meeting compliance for all lines
of business. Maintains good working knowledge of system/internet
and online tools used to process claims • Good knowledge of
CPT/HCPCS/ICD-10, and Revenue Codes, including modifiers. • Assist
customer service as needed to assist in claims resolution on calls
from providers. • Research authorizations and properly selects
appropriate authorization for services billed. • Coordinate with
the claims clerks on issues related to the submission and
forwarding of claims determined to be financial responsibility of
another organization. • Coordinate Benefits on claims for which
member has another primary coverage • Run monthly reports. • Review
pre and post check run. • Regular and consistent attendance • Other
duties as assigned QUALIFICATION REQUIREMENTS: To perform this job
successfully, an individual must be able to perform each essential
duty satisfactorily, including regular and consistent attendance.
The requirements listed below are representative of the knowledge,
skill, and/or ability required. Reasonable accommodations may be
made to enable individuals with disabilities to perform the
essential functions. EDUCATION and/or EXPERIENCE: • High School
Diploma or GED required. • 1 to 3 years of previous experience in a
health plan, IPA or medical group. • Strong understanding of the
benefit process including member services or customer service. •
Demonstrated proficiency in MS Office (Excel, Word, Outlook, and
PowerPoint). • Able to navigate difficult situations with empathy,
discretion, and professionalism. • Strong understanding of Senior
Medicare Advantage Health plans. • Able to explain member benefits,
answer questions and concerns using a “Customer Service First”
attitude. • Able to live our mission, vision, and values, •
Bilingual in another language (written and oral) preferred.
Keywords: Astiva Health, Inc, Compton , Claims Examiner I, Customer Service & Call Center , Los Angeles, California
