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AppleOne
Medical Claims Examiner
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Scorecard
Based on California data
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What they do
A Medical Claims Examiner evaluates medical insurance claims in accordance with applicable contracts and government regulations. Verifies that medical treatment costs are accurate given a patient's diagnosis. May specialize in specific types of treatments or types of drug claims.
$54,632 / year median in California
-1% projected decline
Job Description
Job Summary We are seeking a detail-oriented Medical Claims Examiner for a temp-to-hire opportunity in Fremont, CA. This role is ideal for a claims professional with hands-on medical claims adjudication experience who can review, analyze, process, and finalize healthcare claims accurately and efficiently. The Medical Claims Examiner will work in a production-focused administrative and claims processing environment where accuracy, compliance, and timely turnaround are essential. This opportunity offers the chance to contribute to a quality-driven team, work with supportive leadership, and apply your knowledge of healthcare benefits, medical billing, and claims guidelines in a role with long-term potential. The ideal candidate understands the full medical claims lifecycle and can independently determine claim payment, denial, adjustment, or the need for additional information. Key Responsibilities
- Review, process, and adjudicate medical claims in accordance with plan benefits, provider contracts, policies, and regulatory requirements.
- Evaluate claims for eligibility, coverage, coding, authorization requirements, duplicate billing, missing information, and coordination of benefits.
- Determine appropriate payment, denial, adjustment, reconsideration, or reprocessing actions based on claims guidelines.
- Calculate allowable amounts, member responsibility, deductibles, copays, coinsurance, and other applicable benefit provisions.
- Research complex or incorrectly processed claims, document actions taken, and escalate issues when additional review is required.
- Maintain confidentiality of member and healthcare information while meeting productivity, accuracy, quality, and turnaround-time standards. Compensation and Benefits
Compensation:
$87,048 per year.- Employment type: Temp-to-hire.
Location:
Fremont, CA.