Claims Processor: Medical Benefits & Payments Expert

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

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