Health Plan Claims Examiner
About the role
Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.
Responsibilities
- Reviews, evaluates and authorizes payment of medical, dental, vision, and prescription drug claims within the benefit descriptions and plan provisions of a variety of group plans.
- Determines the appropriate course of action on each claim (i.e., payment, further investigation, referral to review, denial, etc.).
- Responds verbally and in writing to claimants and providers regarding plan benefits and eligibility.
- Applies standard claims guidelines, such as coordination of benefits, workers' compensation and third-party investigations.
- Documents claims files regarding every verbal communication.
Requirements
- Education and Work Experience: Associate's/Technical Degree or equivalent combination of education/related experience: Required
- Bachelor's Degree: Preferred
- Three years' experience processing health claims on a computerized claims payment system: Preferred
Essential Functions
- Processes medical claims for payment up to $15,000.00 per Health Plan benefit descriptions.
- Assists in processing of vision and dental claims per Vision and Dental plan descriptions.
- Possesses thorough knowledge of assigned plan benefits, provisions, and exclusions.
- Demonstrates proficiency with ICD-10, CPT and HCPCS codes, modifiers and guidelines, and application of appropriate benefit codes.
- Congnates benefits with primary carriers, when appropriate.
- Congnates with Utilization Review when appropriate.
- Researches and documents rejected or erroneous claims and forwards them to the Health Plan Claims Manager for correction.
- Handles incoming calls from plan members and healthcare providers for assigned plans.
- Maintains established productivity and quality standards of 99% accuracy.
- Participates in special projects as assigned by management.
- Solves and escalates operational problems and technical issues; modifies existing tools or processes.
- Works under general supervision.
- Performs other job-related duties as assigned.
Organizational Requirements
- Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable.
- Medical and religious exemptions may apply.
- Adventist Health participates in E-Verify. Visit here for more information about E-Verify.
About Us
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
JOB INFO
- Job Identification : 63530
- Job Category : Analyst
- Posting Date : 2026-05-27T23:03:31+00:00
- Job Schedule : Full time
- Locations : Roseville, CA, United States
- Assignment Category : Full-time regular
- Pay Range : The estimated base pay for this position is $25.00 to $32.49. Additional individual compensation may be available for this role through differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions. Please contact our Talent Acquisition team for more information.