Medical Claims Examiner

Company: Cornerstone Staffing Solutions – Healthcare Division

Work Location: Fremont, California

Employment Type: Full-Time

Hourly Pay Rate: $41.85 per hour

Schedule: Monday through Friday | 8 hour shifts - 8:30 am to 5:00 pm.

Contract to hire

Position Overview

Cornerstone Staffing Solutions is seeking an experienced Medical Claims Examiner for a full-time opportunity with an established healthcare benefits administration organization in Fremont, California.

The Medical Claims Examiner will review, analyze, and adjudicate healthcare claims in accordance with applicable benefit plans, policies, contracts, regulatory requirements, and internal processing guidelines. This position requires a strong understanding of medical claims, benefit interpretation, healthcare coding, coordination of benefits, and claims payment methodologies.

The successful candidate will be highly accurate, organized, and comfortable working in a structured, production-oriented environment. This individual must be capable of balancing claim-processing productivity with quality, compliance, and professional service to members, providers, and internal departments.

Primary Responsibilities

• Review and adjudicate professional and institutional medical claims accurately and within established turnaround times.
• Verify member eligibility, effective dates, benefit coverage, and applicable plan provisions.
• Review claims for completeness, accuracy, coding consistency, and required supporting documentation.
• Interpret medical benefits, exclusions, limitations, deductibles, copayments, coinsurance, out-of-pocket maximums, and other cost-sharing requirements.
• Examine CPT, HCPCS, ICD-10-CM, revenue, place-of-service, and modifier information as applicable to the claim.
• Determine appropriate payment, denial, pend, or request-for-information actions.
• Apply coordination-of-benefits guidelines and determine primary and secondary payer responsibilities.
• Identify duplicate claims, billing discrepancies, possible overpayments, and other processing concerns.
• Review claims involving prior authorization, medical necessity, timely filing, eligibility, and benefit limitations.
• Research complex claims using benefit documents, internal procedures, provider contracts, and available claim history.
• Request medical records, corrected claims, itemized bills, or other supporting documentation when necessary.
• Document all research, claim decisions, adjustments, and communications clearly within the claims-processing system.
• Process corrected claims, reconsiderations, adjustments, and reprocessed claims according to established procedures.
• Communicate professionally with healthcare providers, members, and internal teams to resolve claim-related questions.
• Assist with appeals, escalated claims, and complex benefit inquiries as assigned.
• Meet established productivity, accuracy, quality, and attendance expectations.
• Protect confidential member and health information in accordance with HIPAA and organizational policies.
• Participate in training, quality reviews, departmental meetings, and process-improvement initiatives.
• Perform additional claims-related duties as assigned.

Common Claims and Services Reviewed

The Medical Claims Examiner may review claims involving:

• Physician and specialist services
• Primary and preventive care
• Urgent care and emergency services
• Inpatient and outpatient hospital care
• Surgical and procedural services
• Diagnostic imaging
• Laboratory and pathology services
• Durable medical equipment
• Rehabilitation and therapy services
• Behavioral and mental health services
• Ambulance and transportation services
• Anesthesia services
• Facility and professional billing
• Coordination of benefits
• Corrected and adjusted claims
• Claim reconsiderations and appeals

Required Qualifications

• At least two years of medical claims examination, adjudication, or healthcare claims-processing experience.
• Demonstrated experience reviewing and processing medical claims in a payer, third-party administrator, benefits administrator, or related healthcare environment.
• Working knowledge of medical terminology.
• Familiarity with CPT, HCPCS, ICD-10-CM, revenue codes, modifiers, and place-of-service codes.
• Understanding of deductibles, copayments, coinsurance, exclusions, benefit maximums, and other healthcare benefit provisions.
• Knowledge of coordination-of-benefits principles.
• Ability to interpret benefit summaries, plan documents, claims procedures, and payment guidelines.
• Strong analytical, investigative, and problem-solving abilities.
• Exceptional accuracy and attention to detail.
• Ability to meet productivity expectations without compromising quality.
• Strong written and verbal communication skills.
• Ability to handle confidential information professionally.
• Proficiency with claims-processing systems, Microsoft Office, and electronic documentation.
• Ability to work independently while contributing effectively within a team environment.

Preferred Qualifications

• Three or more years of medical claims examination experience.
• Experience processing both professional and institutional claims.
• Experience working with self-funded health plans or third-party claims administration.
• Familiarity with provider contracts, fee schedules, allowed-amount calculations, or network pricing.
• Experience reviewing coordination-of-benefits claims, corrected claims, adjustments, appeals, or complex claim scenarios.
• Previous claims auditing, quality assurance, or claims-training experience.
• Experience working in a regulated, production-driven healthcare environment.
• Bilingual communication abilities are beneficial but not required.

Skills and Competencies

The strongest candidates will demonstrate:

• Medical claims adjudication expertise
• Benefit-plan interpretation
• Healthcare coding knowledge
• Mathematical accuracy
• Sound judgment and decision-making
• Strong research and investigative skills
• Consistent productivity and quality
• Clear documentation practices
• Professional member and provider communication
• Organization and time management
• Adaptability to changing procedures
• Accountability and dependability
• Commitment to privacy and compliance

Performance Expectations

Success in this position will be measured through:

• Claims-processing accuracy
• Daily and weekly productivity
• Turnaround-time compliance
• Quality-review results
• Appropriate application of plan provisions
• Completeness of claim documentation
• Attendance and schedule reliability
• Responsiveness to coaching and training
• Professional communication
• Compliance with HIPAA and internal procedures

Why Consider This Opportunity?

This position provides an opportunity to join an established healthcare benefits environment where accuracy, accountability, and service are highly valued.

The selected Medical Claims Examiner will have the opportunity to:

• Apply and expand medical claims expertise.
• Work with a variety of professional and institutional claim types.
• Develop deeper knowledge of benefit interpretation and claims administration.
• Contribute to the accurate and timely resolution of healthcare claims.
• Work within a stable, professional, and collaborative department.
• Build experience with complex claims, adjustments, appeals, and benefit-plan provisions.

Candidate Submission and Confidentiality

This is an opportunity represented through Cornerstone Staffing Solutions – Healthcare Division on behalf of our client.

Do you know another medical professional who could work with you? We pay a referral fee up to $150!