Medical Claims Examiner

Job Description

Job Description

Work Location: Fremont, California

Employment Type: Full-Time

Hourly Pay Rate: $41.85 per hour

Schedule: Monday through Friday | 8 hour shifts - 8:30 am to 5:00 pm.

Contract to hire

Position Overview

Cornerstone Staffing Solutions is seeking an experienced Medical Claims Examiner for a full-time opportunity with an established healthcare benefits administration organization in Fremont, California.

The Medical Claims Examiner will review, analyze, and adjudicate healthcare claims in accordance with applicable benefit plans, policies, contracts, regulatory requirements, and internal processing guidelines. This position requires a strong understanding of medical claims, benefit interpretation, healthcare coding, coordination of benefits, and claims payment methodologies.

The successful candidate will be highly accurate, organized, and comfortable working in a structured, production-oriented environment. This individual must be capable of balancing claim-processing productivity with quality, compliance, and professional service to members, providers, and internal departments.

Primary Responsibilities

• Review and adjudicate professional and institutional medical claims accurately and within established turnaround times.
• Verify member eligibility, effective dates, benefit coverage, and applicable plan provisions.
• Review claims for completeness, accuracy, coding consistency, and required supporting documentation.
• Interpret medical benefits, exclusions, limitations, deductibles, copayments, coinsurance, out-of-pocket maximums, and other cost-sharing requirements.
• Examine CPT, HCPCS, ICD-10-CM, revenue, place-of-service, and modifier information as applicable to the claim.
• Determine appropriate payment, denial, pend, or request-for-information actions.
• Apply coordination-of-benefits guidelines and determine primary and secondary payer responsibilities.
• Identify duplicate claims, billing discrepancies, possible overpayments, and other processing concerns.
• Review claims involving prior authorization, medical necessity, timely filing, eligibility, and benefit limitations.
• Research complex claims using benefit documents, internal procedures, provider contracts, and available claim history.
• Request medical records, corrected claims, itemized bills, or other supporting documentation when necessary.
• Document all research, claim decisions, adjustments, and communications clearly within the claims-processing system.
• Process corrected claims, reconsiderations, adjustments, and reprocessed claims according to established procedures.
• Communicate professionally with healthcare providers, members, and internal teams to resolve claim-related questions.
• Assist with appeals, escalated claims, and complex benefit inquiries as assigned.
• Meet established productivity, accuracy, quality, and attendance expectations.
• Protect confidential member and health information in accordance with HIPAA and organizational policies.
• Participate in training, quality reviews, departmental meetings, and process-improvement initiatives.
• Perform additional claims-related duties as assigned.

Common Claims and Services Reviewed

The Medical Claims Examiner may review claims involving:

• Physician and specialist services
• Primary and preventive care
• Urgent care and emergency services
• Inpatient and outpatient hospital care
• Surgical and procedural services
• Diagnostic imaging