Claims Processor

Delta Health Systems Mcc; Fresno (CA); On-site; USD 28,000 - 43,000; Full time

Job summary

Delta Health Systems in Fresno is seeking a Claims Processor to evaluate and adjudicate claims based on Plan provisions, Medical Policy, and guidelines. The role requires meticulous attention to detail, clear communication, and resilience under pressure.

You will maintain claim notes, manage COB files, and respond to inquiries from participants, providers, and unions. A high school diploma and 18 months of related experience are required; medical terminology coursework may substitute for

Qualifications

• High school diploma or equivalent; medical terminology coursework may substitute for six months of experience.
• 18 months experience as a Claims Processor or similar function; strong medical terminology knowledge.

Responsibilities

• Evaluate claims, determine payment or denial according to Plan provisions, Medical Policy, and guidelines.
• Process claim payments thoroughly, attend training and refresher courses.
• Maintain clear claim notes and benefit quote documentation; review patient and family notes.
• Establish and maintain COB files; apply COB payments for final claim payment.
• Research CPT procedure and ICD-10 Diagnosis Codes.
• Respond to written correspondence from participants, providers, and unions.
• Navigate external network pricing platforms; prioritize workload to meet standards.
• Perform other duties as assigned and maintain professionalism.

Skills

Written communication

Oral communication

Judgment

Education

High school diploma or equivalent

Job description

Job Details: Job Location: Fresno Claims Office - Fresno, CA 93720, Position Type: Full Time, Salary Range: $20.50 - $31.00 Hourly, Job Category: Customer Service, Delta Health Systems, one of the leading Third Party Administrators (TPA) for self insured programs in the country with a reputation for flexibility, innovative services and outstanding customer service is looking for an innovative, self motivated, dedicated individual to fill the position of:

Claims Processor

• Evaluate claims, determine payment or denial according to Plan provisions, Medical Policy, and guidelines.
• Process claim payment thoroughly, attend all training, and refresher courses.
• Maintain clear claim notes, benefit quote documentation, thoroughly review patient and family notes.
• Maintain multiple network access for pricing and authorization to avoid inactivity and disruption for processing.
• Establish and maintain COB files, applies COB payments for final claim payment.
• Applies COB payments for final claim payment.
• Research and determine proper CPT procedure and ICD-10 Diagnosis Codes.
• Research and respond to written correspondence from participants, providers, and local unions/employers.
• Transfer claims to Benefit Review for processing instructions and or other departments according to guidelines.
• Work effectively to achieve at a minimum production, quality, and accuracy standards.
• Display maturity, composure and ability to operate under stress conditions.
• Follow department policy and procedures distributed.
• Attend mandatory department meetings as scheduled.
• Assist other department areas as required dependent on workload and inventory needs.
• Excellent organization and assignment management skills.
• Clear communication with internal and external customers.
• Ability to Navigate in external network pricing platforms.
• Ability to prioritize workload and adhere to network administrative agreements.
• Maintains professionalism at all times.
• Perform other duties as assigned.

Qualifications

Education

High school diploma or equivalent. Satisfactory completion of medical terminology course may substitute for six (6) months of equivalent experience.

Experience

Eighteen (18) months experience as a Claims Processor or similar function. Must have a broad knowledge of medical terminology and must possess excellent written and oral communication skills. Must possess good judgment skills and ability to interpret Department guidelines and contractual benefits.

Any employee who is not in a probationary status and meets the qualifications of this position (as stated above) shall be eligible to apply for this position.