Claims Processor, Entry Level

This is a fully remote position, open to applicants in California.

📋 Description

• Review and process medical, dental, vision, electronic, and HIPD claims.

• Handle claims in accordance with state, federal, health plan regulatory requirements, and department protocols.

• Achieve established quality and production performance standards.

• Conduct research and review relevant documentation.

• Meticulously review, analyze, and investigate health care claims.

• Identify discrepancies and confirm pricing accuracy.

• Verify prior authorizations.

• Process claims for payment efficiently.

• Assist in resolving issues from providers, customer service, member services, health plans, and other internal stakeholders.

• Analyze problems, data, or text while weighing multiple perspectives and consequences before making decisions.

• Collaborate with colleagues to document and analyze functional requirements, identify gaps, and explore alternative solutions.

• Contribute to the definition and documentation of standards, ensuring alignment with industry benchmarks.

• Notify supervisors of potential high-risk compliance concerns.

• Recognize issues, resolve problems, research, identify trends, and determine necessary actions.

• Follow up as needed and engage the appropriate parties in problem resolution.

• Report directly to the Supervisor of Claims.

⛳️ Requirements

• Recent certification in Medical Billing or Medical Coding.

• Must reside within 60 miles of Fresno, CA.

• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and benefit determination.

• Strong verbal and written communication skills.

• Proficient in 10-key by touch.

• Capable of data entry at a speed of 40 WPM.

• Proficient in Microsoft Office (Word, Excel, Outlook, PowerPoint).

• Ability to quickly learn new applications.

• Ability to work effectively under pressure and adapt to a dynamic environment.

• Working knowledge of ERISA claims processing and adjudication guidelines.

• Ability to ensure compliance with relevant policies, practices, and all applicable local, state, and federal regulations regarding claims and contract administration.

• Entry-level position.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Critical Illness, Accident, and Hospital insurance.

• 401(k) Retirement Plan with options for pre-tax and Roth post-tax contributions.

• Life Insurance (Voluntary Life & AD&D for employees and dependents).

• Short and long-term disability benefits.

• Health Spending Account (HSA).

• Transportation benefits.

• Employee Assistance Program.

• Time Off/Leave options (PTO, Vacation, or Sick Leave).