Remote - Claims Processor (Entry Level)

About the role

The Claims Examiner I reports to the Supervisor of Claims and is responsible for reviewing and processing medical, dental, vision and electronic claims in accordance with state, federal and health plan regulatory requirements, department guidelines, as well as meeting established quality and production performance benchmarks. The incumbent will also process Health Insurance Payment Demand (HIPD) claims. The role involves thoroughly reviewing, analyzing, and researching health care claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position assists in resolving issues from providers, customer service, member services, health plan, and other internal customers.

Responsibilities

• Review and process medical, dental, vision and electronic claims in accordance with regulatory and departmental requirements
• Meet established quality and production performance benchmarks
• Research and review applicable documentation to adjudicate claims
• Process Health Insurance Payment Demand (HIPD) claims
• Identify discrepancies, verify pricing, and confirm prior authorizations
• Assist in resolving issues from providers, customer service, member services, health plan, and other internal customers
• Interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and/or benefit determination
• Ensure compliance with all appropriate policies, practices, local, state, and federal regulations
• Partner with peers to document and analyze functional requirements, identify gaps, and resolve problems
• Contribute to defining and documenting standards and periodically reviewing them to integrate appropriate industry standards
• Alert supervisors to potential higher-risk compliance issues
• Make timely and effective decisions based on available information
• Recognize issues, analyze and solve problems, research, identify trends, and determine actions needed to advance decision-making within a realistic timeframe
• Follow up as necessary and involve the appropriate people in defining, understanding the impact, and resolving problems

Requirements

• Recent Medical Billing or Medical Coding Certification
• Must live within 60 miles of Fresno, CA

Additional Skills & Qualifications

• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and/or benefit determination
• Good verbal and written communication skills
• Proficient in 10-key by touch data entry/type 40 WPM
• Proficient in Microsoft Office (Word, Excel, Outlook, PowerPoint)
• Capability to quickly learn new applications
• Ability to work under pressure and adapt to a changing environment
• Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines
• Ability to examine a problem, set of data or text, consider multiple sides of an issue, weigh consequences before making a final decision

Pay

The pay range for this position is $20.00 - $22.00/hr. Individual compensation offered within this range will depend on qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Benefits

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

Schedule

This is a fully remote position.