Medical Claims Examiner

2 weeks ago

Fresno, California, United States TEKsystems Full time
:

The Claims Examiner I reports to the Supervisor of Claims.

Claims Examiner I 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 meet established quality and production performance benchmarks to include research and review of applicable documentation.

The incumbent will also process Health Insurance Payment Demand (HIPD) claims.

The Claims Examiner I will thoroughly review, analyze, and research health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment.

The position will assist in resolving issues from providers, customer service, member services, health plan, and other internal customers.

Additional Skills & Qualifications:

  • High school education or equivalent
:

minimum one (1) to three (3) years year of experience as a Health Claims Examiner or comparable industry experience preferrecd.


  • A minimum of one (1)year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims
  • Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination
  • Basic knowledge of medical terminology. Familiar with UB04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
  • Good verbal and written communication skills.
  • Proficient in 10key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
  • Ability to work under pressure and adapt to changing environment
  • Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.


Examine a problem, set of data or text and consider multiple sides of an issue, weighs consequences before making a final decision.


  • Ensure compliance with all appropriate policies and practices, local, State, Federal regulations and requirements regarding claims and contract administration.
  • Partner with peers to document and analyze functional requirements, identify gaps and alternative approaches to 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, analyzes, solves problems, researches, identifies trends and determines actions needed to advance the decisionmaking process within a realistic timeframe. Follows up as necessary.
  • Involve the appropriate people in defining, understanding the impact and resolving problems.
Experience Level:

Intermediate Level

About TEKsystems:

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity.

We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia.

As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change.

That's the power of true partnership. TEKsystems is an Allegis Group company.


The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

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