Payer-Side Claims Processing
AppleOne Employment Services · Bakersfield, CA · 6 days ago
Healthcare$46k–$48k/yrContract
Responsibilities
- Review, audit, and process medical and facility claims accurately and within established service levels
- Apply contract benefits, policies, and payment guidelines
- Resolve suspended and pended claims involving:
- Primary Care Providers (PCPs)
- Laboratory services
- Radiology services
- Physical Therapy services
- Specialist claims
- Investigate and resolve Coordination of Benefits (COB) issues
- Verify member eligibility and other insurance coverage
- Identify billing errors, inconsistencies, and potential fraudulent claim activity
- Calculate benefits and reimbursements when manual review is required
- Deny claims according to policy and contractual guidelines
- Route complex claims to appropriate departments for further review
- Maintain productivity and quality standards
Requirements
- High School Diploma or equivalent
- Minimum 1–2 years of medical claims processing
- Experience on the payer side
- Experience adjudicating claims for a health plan, insurance carrier, managed care organization, HMO, Medicare, Medicaid, or third-party administrator
- Experience investigating and resolving Coordination of Benefits (COB) issues
- Experience reviewing professional and facility claims for payment accuracy
- Ability to calculate usual, customary, prevailing, or contract-based reimbursement rates