Claims Examiner-Stop Loss Coord Sr CCH

Community Medical Centers; Fresno (CA); On-site; USD 41,000 - 55,000; Full time

Benefits offered by this job

Free continuing education

Tuition reimbursement

Day-1 vacation

403(b) plan

Free parking

EV charging

Job summary

Community Medical Centers seeks a Senior Claims Examiner and Stop Loss Coordinator to review complex professional and hospital claims for in-network and out-of-network providers. You will verify pricing, confirm prior authorizations, and process payments while tracking stop loss members and filing timelines with the carrier.

Ideal candidates bring 4+ years in medical claims processing, experience with claims systems, and knowledge of CMS guidelines as they relate to stop loss policy compliance.

Qualifications

• 4 years of medical claims processing/adjudication experience required.
• Experience working with claims system/applications and troubleshooting.
• TriZetto/QNXT system knowledge preferred.

Responsibilities

• Review and process complex professional and hospital claims for in-network and out-of-network providers.
• Verify pricing, confirm prior authorization, and process payments.
• Track stop loss members and timely filing of all stop loss claims with the carrier.
• Train staff on claims system enhancements.

Education

High School Diploma, HSE or CHS IEP Certificate

Associate's Degree preferred

Tools

TriZetto/QNXT

Job description

Overview

Opportunities for you!

• Consecutively recognized as a top employer by Forbes, and in 2025 by Newsweek
• Free Continuing Education and certification
• Tuition reimbursement, education programs and scholarships
• Vacation time starts building on Day 1, and builds with your seniority
• Free money toward retirement with a 403(b) and matching contributions
• Great food options with on-demand ordering
• Free parking and electric charging

Commitment to diversity and inclusion is a cornerstone of our culture at Community. All are welcome as valued members of our community.

We know that our ability to provide the highest level of care is through taking care of our incredible teams. Learn more on our Benefits page.

Responsibilities

The Senior Claims Examiner and Stop Loss Coordinator is responsible for reviewing and processing complex professional and hospital claims for Community Care Health (CCH) in-network and out-of-network providers. This role will review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorization, and process them for payment. Tracks potential and existing stop loss members, timely filing of all stop loss claims with the carrier, follow-up with the carrier regarding outstanding recoveries, and reporting. Provides overall assurance that CCH is in compliance with the stop loss policy. Trains new or existing staff on any claims system enhancements.

• Ideal Background:
• Experience with self-funded, tribal, and non-tribal insurance plans.
• Experience with Blue Shield (due to current integration).
• Alternative Strong Backgrounds:
• Medicare Experience: Even though the role does not handle these lines directly, The department heavily utilizes CMS guidelines in their processing, so Medicare knowledge overlaps by 80% to 90%.

Qualifications

Education

• High School Diploma, High School Equivalency (HSE) or Completion of a CHS Approved Individualized Education Plan (IEP) Certificate required
• Associate's Degree preferredExperience
• 4 years of medical claims processing/adjudication experience required
• Experience working with claims system/applications and troubleshooting
• TriZetto/QNXT system knowledge preferred

Disclaimers

• Pay ranges listed are an estimate and subject to change.
• If any bonuses are noted, they are only applicable to external hires meeting criteria.