Claims Examiner I
WESTERN GROWERS GROUP —Fresno, CA
- $40,580.28 - $52,756.02 a year
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- HIPAA
- Dental insurance
- Vision insurance
Quick Apply
Xcelys Medical Claims Examiner (Remote)
NTT DATA —Ontario, CA
- $20 an hour
- Contract
- Remote
- Mid-level
- High school diploma or GED
- Analysis skills
- Health savings account
- AD&D insurance
Quick Apply
10d
Senior Claims Examiner
WESTERN GROWERS ASSURANCE TRUST —Fresno, CA
- $53,667.86 - $69,768.32 a year
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- HIPAA
- Flexible spending account
Quick Apply
Workers Compensation Claims Examiner III _ Temp
TRISTAR RISK MANAGEMENT —Chino Hills, CA
- $93,600 - $104,000 a year
- Temporary
- Remote
- Microsoft Word
- Writing skills
- Basic math
- Paid holidays
- Disability insurance
Quick Apply
Workers Compensation Claims Examiner III
TRISTAR RISK MANAGEMENT —Signal Hill, CA
- $90,000 - $100,000 a year
- Full-time
- Remote
- Microsoft Word
- Writing skills
- Basic math
- Paid holidays
- Disability insurance
Quick Apply
Claims Adjuster Senior
Gallagher —Torrance, CA
- $61,000 - $119,000 a year
- Full-time
- Remote
- 5 years
- High school diploma or GED
- Bachelor's degree
- Paid parental leave
- Health savings account
Senior Workers Compensation Claims Examiner
Next Level Administrators, LLC —Murrieta, CA
- $95,000 - $110,000 a year
- Remote
- 5 years
- High school diploma or GED
- Analysis skills
- Commuter assistance
- Paid parental leave
Claims Examiner, General Liability Claims
Gallagher —Torrance, CA
- $76,500 - $110,000 a year
- Full-time
- Remote
- 5 years
- Mid-level
- High school diploma or GED
- Paid parental leave
- Health savings account
Product SME - Workers Compensation
Assured —Palo Alto, CA
- $120,000 - $140,000 a year
- Full-time
- Remote
- Organizational skills
- Senior level
- Health savings account
- Paid holidays
Claims Examiner - Workers Compensation | CA WC Experience Required
Sedgwick —California
- Full-time
- Remote
- Customer service
- Bachelor's degree
- Fair chance
- Health savings account
- Disability insurance
Plan Coder
WESTERN GROWERS ASSURANCE TRUST —Irvine, CA
- $46,669.19 - $60,668.60 a year
- Full-time
- Remote
- Computer Science
- Bachelor of Science
- Writing skills
Quick Apply
Supervisor Property Mid Loss
Mercury Insurance Services, LLC —Los Angeles, CA
- $77,283 - $179,048 a year
- Remote
- Microsoft Excel
- Mid-level
- Analysis skills
- Paid holidays
- Health insurance
Senior Claims Examiner, Workers' Compensation
Gallagher —San Jose, CA
- $61,000 - $119,000 a year
- Full-time
- Remote
- 5 years
- High school diploma or GED
- Bachelor's degree
- Paid parental leave
- Health savings account
Senior Claims Examiner, Complex General Liability
Gallagher —Torrance, CA
- $88,000 - $171,500 a year
- Full-time
- Remote
- 7 years
- High school diploma or GED
- Bachelor's degree
- Paid parental leave
- Health savings account
Product SME - Commercial Property
Assured —Palo Alto, CA
- $120,000 - $140,000 a year
- Full-time
- Remote
- Organizational skills
- Senior level
- Commercial
- Health savings account
- Paid holidays

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remote medical claims examiner jobs near california

Claims Examiner I

WESTERN GROWERS GROUP
Fresno, CA

Quick Apply

Job Details

Full-time
$40,580.28 - $52,756.02 a year

Benefits

Dental insurance
Vision insurance

Qualifications

Research

Full Job Description

Job Description Summary

The Claims Examiner I reports to the Supervisor of Claims. Claims Examiner I is responsible for reviewing and processing medical, dental, vision, and electronic claims per state, federal, and health plan regulatory requirements and department guidelines, as well as meeting established quality and production performance benchmarks, including research and review of applicable documentation. The Claims Examiner I will thoroughly review, analyze, and research health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position will assist in resolving issues from providers, customer service, member services, health plan, and other internal customers.

Duties And Responsibilities

Claims Processing & Quality Assurance

Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
Analyze patient and medical records to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation.
Research through all vendor portals, including but not limited to Valenz, Occunet, Anthem
Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines. Process low to medium level claims, re-pricing corrections.
Research, resolve and respond to all correspondence and internal communication (Ops Connect) related to electronic and paper claims as assigned.
Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.
Meet and maintain individual and department productivity and quality standards.

Problem Solving, Judgement & Compliance

Examine a problem, set of data or text and consider multiple sides of an issue, weighs consequences before making a final decision.
Ensure compliance with all appropriate policies and practices, local, State, Federal regulations and requirements regarding claims and contract administration.
Partner with peers to document and analyze functional requirements, identify gaps and alternative approaches to resolve problems.
Contribute to defining and documenting standards and periodically reviewing them to integrate appropriate industry standards.
Alert supervisors to potential higher risk compliance issues
Make timely and effective decisions based on available information
Recognize issues, analyzes, solves problems, researches, identifies trends and determines actions needed to advance the decision-making process within a realistic timeframe. Follows up as necessary.
Involve the appropriate people in defining, understanding the impact and resolving problems.

Other

Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
Maintain internet speed of 40MB download and 10MB upload and router with wired Ethernet.
Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
Maintain and service safety equipment (e.g. smoke detector, fire extinguisher, first aid kit).
All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.

Qualifications

High school education or equivalent: minimum three (3) to five (5) years of experience as a Health Claims Examiner or comparable industry experience preferred.
A minimum of one (1) year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims, highly desired.
Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination
Basic knowledge of medical terminology. Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
Good verbal and written communication skills.
Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
Ability to work under pressure and adapt to changing environment
Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.
Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
Home router with wired Ethernet (wireless connections and hotspots are not permitted).
A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
A functioning smoke detector, fire extinguisher, and first aid kit on site.

Quick Apply

Refine Your Search

remote medical claims examiner jobs in california

Claims Examiner I

Xcelys Medical Claims Examiner (Remote)

Senior Claims Examiner

Workers Compensation Claims Examiner III _ Temp

Workers Compensation Claims Examiner III

Claims Adjuster Senior

Senior Workers Compensation Claims Examiner

Claims Examiner, General Liability Claims

Product SME - Workers Compensation

Claims Examiner - Workers Compensation | CA WC Experience Required

Plan Coder

Supervisor Property Mid Loss

Senior Claims Examiner, Workers' Compensation

Senior Claims Examiner, Complex General Liability

Product SME - Commercial Property

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