Medical Claims Examiner

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!

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 location )

hourly rate: $40.75 hourly

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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