What are the responsibilities and job description for the Claims Examiner position at AppleOne Employment Services?
As a claims examiner for this medical facility you will be responsible for reviewing and processing medical and facility claims accurately and timely, ensuring compliance with contract benefits, policies, and procedures. This role focuses on claims adjudication and auditing, not billing.
Key Responsibilities
Review and process all types of medical and facility claims from providers and members.
Apply correct contract benefits and organizational policies.
Resolve system-suspended claims for PCPs, labs, radiology, and less complex specialists.
Deny inappropriate claims following policy guidelines.
Identify billing errors and potential fraudulent submissions.
Verify eligibility and other health insurance coverage via online systems.
Perform manual benefit calculations when necessary.
Route complex claims to appropriate departments for further review.
Maintain productivity and quality standards.
Adhere to company policies and procedures.
Required Qualifications
High School Diploma or equivalent.
Minimum 1 year of medical claims processing experience (not billing).
Experience With Med-Cal And Managed Care Environments Preferred.
Knowledge of:
Medical terminology
HCPCS, CPT, ICD-10 coding
UB04 and CMS1500 forms
Apply for this great position as a claims examiner today! please send resumes to Yarely Villalpando at yvillalpando(@)appleone.com
Equal Opportunity Employer / Disabled / Protected Veterans
The Know Your Rights poster is available here:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf
The pay transparency policy is available here:
https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_ English_formattedESQA508c.pdf
For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.
We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.
AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.
https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf
We also consider for employment qualified applicants regardless of criminal histories, consistent with legal requirements, including, if applicable, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records, including, if applicable, the San Francisco Fair Chance Ordinance. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
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Key Responsibilities
Review and process all types of medical and facility claims from providers and members.
Apply correct contract benefits and organizational policies.
Resolve system-suspended claims for PCPs, labs, radiology, and less complex specialists.
Deny inappropriate claims following policy guidelines.
Identify billing errors and potential fraudulent submissions.
Verify eligibility and other health insurance coverage via online systems.
Perform manual benefit calculations when necessary.
Route complex claims to appropriate departments for further review.
Maintain productivity and quality standards.
Adhere to company policies and procedures.
Required Qualifications
High School Diploma or equivalent.
Minimum 1 year of medical claims processing experience (not billing).
Experience With Med-Cal And Managed Care Environments Preferred.
Knowledge of:
Medical terminology
HCPCS, CPT, ICD-10 coding
UB04 and CMS1500 forms
Apply for this great position as a claims examiner today! please send resumes to Yarely Villalpando at yvillalpando(@)appleone.com
Equal Opportunity Employer / Disabled / Protected Veterans
The Know Your Rights poster is available here:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf
The pay transparency policy is available here:
https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_ English_formattedESQA508c.pdf
For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.
We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.
AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.
https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf
We also consider for employment qualified applicants regardless of criminal histories, consistent with legal requirements, including, if applicable, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records, including, if applicable, the San Francisco Fair Chance Ordinance. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
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