Claims Adjudication Specialist – Medical Benefits

Cornerstone Staffing Solutions, Inc.; Fremont (CA); On-site; USD 86,000 - 93,000; Full time

Benefits offered by this job

Referral program

Job summary

Cornerstone Staffing Solutions – Healthcare Division in Fremont, California is seeking an experienced Medical Claims Examiner for a full-time, contract-to-hire role. You will review, adjudicate, and process professional and institutional medical claims in accordance with benefit plans, policies, and regulatory requirements.

The ideal candidate has at least two years of claims-processing experience, strong knowledge of CPT/HCPCS/ICD-10-CM, and excellent attention to detail to ensure accurate,

Qualifications

• At least two years of medical claims examination, adjudication, or healthcare claims-processing experience.
• Working knowledge of medical terminology.
• Familiarity with CPT, HCPCS, ICD-10-CM, revenue codes, modifiers, and place-of-service codes.

Responsibilities

• Review and adjudicate professional and institutional medical claims accurately and within established turnaround times.
• Verify member eligibility, effective dates, benefit coverage, and applicable plan provisions.
• Review claims for completeness, accuracy, coding consistency, and required supporting documentation.
• Interpret medical benefits, exclusions, limitations, deductibles, copayments, coinsurance, out-of-pocket maximums, and other cost-sharing requirements.
• Examine CPT, HCPCS, ICD-10-CM, revenue, place-of-service, and modifier information as applicable to the claim.
• Determine appropriate payment, denial, pend, or request-for-information actions.
• Apply coordination-of-benefits guidelines and determine primary and secondary payer responsibilities.
• Identify duplicate claims, billing discrepancies, possible overpayments, and other processing concerns.
• Review claims involving prior authorization, medical necessity, timely filing, eligibility, and benefit limitations.
• Communicate professionally with healthcare providers, members, and internal teams to resolve claim-related questions.
• Meet established productivity, accuracy, quality, and attendance expectations.
• Protect confidential member and health information in accordance with HIPAA and organizational policies.

Skills

Medical claims adjudication

Attention to detail

Communication

Independent worker

Tools

Microsoft Office

Claims-processing system

Job description

Cornerstone Staffing Solutions – Healthcare Division in Fremont, California is seeking an experienced Medical Claims Examiner for a full-time, contract-to-hire role. You will review, adjudicate, and process professional and institutional medical claims in accordance with benefit plans, policies, and regulatory requirements.

The ideal candidate has at least two years of claims-processing experience, strong knowledge of CPT/HCPCS/ICD-10-CM, and excellent attention to detail to ensure accurate,