Medical Claims Representative

Job Description

Job Description

We are looking for a Medical Claims Representative to join our team in Pleasanton, California in a Contract to Permanent role. This position is ideal for someone with experience handling medical claims, billing activity, and insurance-related documentation in a fast-paced environment. The person in this role will support accurate claim review and member-related processing while communicating clearly with Spanish-speaking members and internal teams. Success in this position requires strong knowledge of medical terminology, benefit plans, and claims administration procedures.

Responsibilities:
• Review, evaluate, and process medical claims with close attention to accuracy, completeness, and applicable coverage details.
• Enter and maintain member, enrollment, beneficiary, and medical information within internal claims systems while following established procedures.
• Verify insurance details and confirm benefit eligibility to support timely and correct claim handling.
• Interpret billing information, coding details, and supporting documentation to determine appropriate claim outcomes.
• Communicate with members, providers, and internal partners regarding claim status, required documentation, and benefit-related questions.
• Assist Spanish-speaking members by providing clear and thorough support in both English and Spanish.
• Apply working knowledge of healthcare benefits, policies, and regulatory guidelines when reviewing claim activity.
• Escalate complex or legally sensitive claim matters to leadership when additional review or direction is needed.• Prior experience in medical claims processing, claim administration, or medical billing is required.
• Bilingual fluency in English and Spanish is required for effective communication with members.
• Strong understanding of medical terminology and its application in billing or claims review.
• Knowledge of insurance verification, benefit structures, and healthcare-related policies and procedures.
• Ability to read and interpret billing codes, claim documents, and supporting records with accuracy.
• Basic proficiency in Microsoft Excel and confidence learning new claims or member information systems.
• Strong written and verbal communication skills with the ability to manage high-volume workloads effectively.