Medical Payers Side Claims 1yr exp

AppleOne Employment Services; Bakersfield (CA); On-site; USD 42,000 - 60,000; Full time

Job summary

AppleOne Employment Services is seeking an experienced payer-side Medical Claims Examiner to review and adjudicate medical and facility claims with accuracy. Candidates must have hands-on health plan, HMO, insurance carrier, or TPA experience and be able to handle high-volume workloads during peak seasons.

Minimum 1 year of payer-side processing, strong knowledge of medical terminology and coding, and proficiency in data entry and standard office software are required.

Qualifications

• Minimum 1 year of payer-side medical claims processing experience.
• Experience adjudicating medical and facility claims for a health plan, HMO, insurance carrier, or TPA.
• High School Diploma or equivalent.

Responsibilities

• Review and process medical and facility claims accurately and efficiently.
• Adjudicate claims according to established benefit plans and guidelines.
• Resolve suspended and exception claims.
• Research eligibility and coverage information.
• Identify billing discrepancies and potential claim issues.
• Process claim denials following policy requirements.
• Calculate benefits and payments when needed.
• Escalate complex claims for additional review.
• Maintain productivity and quality standards.
• Document claim activity and processing outcomes.
• Collaborate with internal departments to support claim resolution.
• Ensure compliance with healthcare regulations and company policies.
• As the busy healthcare season approaches, we’re seeking professionals who thrive in a high-volume environment and enjoy using their expertise to solve problems and deliver accurate results.

Skills

Analytical thinking

Attention to detail

Communication skills

Independent worker

Data entry

Education

High School Diploma

Tools

Microsoft Excel

Outlook/Word

Job description

Job Overview

Are you an experienced payer-side Medical Claims Examiner looking for your next opportunity? We are seeking detail-oriented professionals with hands-on health plan, HMO, insurance carrier, or third-party administrator (TPA) claims processing experience. Important: Candidates must have recent payer-side medical claims adjudication experience. Join a team where your claims expertise, attention to detail, and healthcare knowledge make a direct impact. Please note: Payer-side claims adjudication experience is a mandatory requirement. Applicants without direct health plan, insurance carrier, HMO, or TPA claims processing experience will not be considered.

Qualifications

Required Experience

• Minimum 1 year of payer-side medical claims processing or claims examiner experience
• Experience adjudicating medical and facility claims for a health plan, HMO, insurance carrier, or TPA
• High School Diploma or equivalent

Required Knowledge

• Medical terminology
• CPT, HCPCS, and ICD-10 coding
• CMS-1500 and UB-04 claim forms
• Eligibility verification processes
• Benefits and claims adjudication guidelines
• Healthcare claims policies and procedures

Computer Skills

• Experience with computerized claims processing systems
• Strong data entry and system navigation skills
• Microsoft Outlook, Word, and Excel proficiency preferred
• Ability to work across multiple systems while maintaining accuracy

Required Skills

• Strong analytical and problem-solving abilities
• Excellent organizational skills
• High attention to detail
• Ability to work independently in a fast-paced environment
• Strong written and verbal communication skills

Responsibilities

• Review and process medical and facility claims accurately and efficiently
• Adjudicate claims according to established benefit plans and guidelines
• Resolve suspended and exception claims
• Research eligibility and coverage information
• Identify billing discrepancies and potential claim issues
• Process claim denials following policy requirements
• Calculate benefits and payment amounts when needed
• Escalate complex claims for additional review
• Maintain productivity and quality standards
• Document claim activity and processing outcomes
• Collaborate with internal departments to support claim resolution
• Ensure compliance with healthcare regulations and company policies
• As the busy healthcare season approaches, we’re seeking professionals who thrive in a high-volume environment and enjoy using their expertise to solve problems and deliver accurate results.

Equal Opportunity Employer / Disabled / Protected Veterans

The Know Your Rights poster is available here: https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf

The pay transparency policy is available here: https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf

For temporary assignments lasting 13 weeks or longer, AppleOne is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.

We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.

AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program. https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf

We also consider for employment qualified applicants regardless of criminal histories, consistent with legal requirements, including, if applicable, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment‑qualified applicants with arrest and conviction records, including, if applicable, the San Francisco Fair Chance Ordinance. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.