Job Description

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 or remote depending on experience/location )

Salary: $68,000 - $74,000 (experience contingent)

Schedule: Full-Time,

Position type: Direct Hire opportunity

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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.

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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.

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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.

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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.

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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.

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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

Tags:

#MedicalClaims #ClaimsExaminer #InsuranceJobs #HealthcareAdmin #ClaimsProcessing #OnsiteJob #FremontJobs #MedicalTerminology #BilingualJobs #PPO #HIPAA #HealthcareJobs

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