We are seeking a Medical Claims Examiner ready to expand on their established career to partner with our client to impact and support patients in need.
Out-of-state applicants are welcome to apply, and must have Anthem Blue Cross Systems claims processing experience.
If you seek in-depth training, a positive office culture & career expansion. Then we look forward to connecting with you.
Bilingual training/ expertise: Spanish preferred
Location: Fremont, CA (Onsite Only)
Salary: $68,000 - $74,000 (experience contingent)
Schedule: Full-Time,
Position type: Direct Hire opportunity
Overview:
We are seeking a detail-oriented and professional Claims Examiner to join our client in Fremont, CA. This role offers a dynamic opportunity for experienced medical claims professionals to leverage their skills in a supportive, high-performing environment. Bilingual proficiency in Spanish is highly desirable.
This is a full-time, onsite position with no remote or hybrid options available.
Key Responsibilities:
The Claims Examiner is responsible for accurately processing various medical insurance claims for both active and retired participants in accordance with plan benefits, department procedures, and applicable regulations.
- Duties include, but are not limited to:
- Review, interpret, and adjudicate claims in alignment with plan rules, eligibility, exclusions, and limitations.
- Utilize knowledge of PPO provider guidelines, Medicare coordination, and supplemental benefits during claims review.
- Engage in claims processing using online adjudication systems, including systems provided by current carriers (e.g., Anthem Blue Cross).
- Accurately input and edit claim data using Microsoft Word, Excel, and Access.
- Provide professional-level customer service and assist participants with benefit-related inquiries.
- Maintain detailed records of communications, including call summaries and eligibility verifications.
- Operate office equipment such as computers, ten-key calculators, scanners, and fax machines.
- Attend staff meetings and training sessions as needed.
- Support internal audits and contribute to department goals as assigned by management.
Customer Service Component:
When serving as a Customer Service Representative:
- Respond to participant and provider inquiries regarding eligibility, plan benefits, and claim statuses.
- Quote plan language accurately without providing interpretive advice.
- Document interactions thoroughly in both written and electronic formats.
Knowledge, Skills, and Abilities:
- Minimum 2 years of recent experience processing medical and dental claims online.
- Solid understanding of group benefit plans and claims processing procedures.
- Familiarity with HIPAA, Health Care Reform regulations, medical terminology, and coding systems (CPT, ICD-9, ICD-10, HCPCS).
- Strong analytical and critical thinking skills.
- Proficiency in Microsoft Word, Excel, and Outlook.
- Ten-key by touch and strong data entry accuracy.
- Ability to perform complex mathematical calculations involving percentages and formulas.
- Excellent written and verbal communication skills.
- Detail-oriented and able to organize and manage time effectively.
- Ability to work collaboratively within a team and adapt to evolving responsibilities.
Physical & Mental Requirements:
- Must be able to sit for extended periods and perform repetitive tasks.
- Strong attention to detail and the ability to focus in a busy office setting.
- Ability to meet productivity benchmarks while maintaining quality and accuracy.
Testing Requirements:
Applicants must complete the following assessments:
- Written and verbal claims examiner evaluation
- Online cognitive/reasoning and reading comprehension assessments
- Microsoft Word, Excel, and Outlook proficiency tests
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