Claims Examiner

Job Summary

We are seeking a detail-oriented Claims Examiner for a direct hire opportunity in Fremont, CA. This role is ideal for a medical and dental claims professional with strong accuracy, analytical ability, and experience processing claims in a fast-paced insurance or benefits administration environment.

The Claims Examiner will review, interpret, and process group benefit claims while ensuring plan documents, eligibility rules, limitations, exclusions, HIPAA requirements, and applicable coding standards are followed. This is a strong opportunity for someone who enjoys structured work, clear production goals, supportive team collaboration, and the ability to build deeper expertise in claims systems, benefit plans, and healthcare reimbursement processes.

Key Responsibilities

- Process medical and dental claims accurately using online claims systems and applicable carrier platforms.
- Interpret group benefit plan documents, eligibility, limitations, exclusions, PPO guidelines, coordination of benefits, Medicare, and supplemental plan benefits.
- Recalculate claims using formulas, percentages, multiplication, and detailed benefit provisions to ensure accurate payment outcomes.
- Communicate professionally with providers and participants by phone, email, correspondence, fax, or in person regarding eligibility, benefits, and claim-related questions.
- Maintain accurate documentation of calls, eligibility requests, benefit inquiries, and claim activity.
- Assist auditors, managers, and team members with claims research, documentation, reporting, and other assigned duties.

Compensation and Benefits

- Salary: $87,048 per year.
- Job Type: Direct Hire.
- Location: Fremont, CA.

Required Qualifications and Skills

- Process online medical and dental claims in accordance with plan benefits, eligibility rules, limitations, and exclusions.
- Review and recalculate claims using medical codes, benefit formulas, percentages, and coordination of benefits rules.
- Communicate with providers, participants, internal team members, auditors, and management regarding claims, eligibility, and benefits.
- Maintain accurate documentation, meet production benchmarks, and uphold quality standards in a high-volume claims environment.

- Minimum of 2 years of current experience processing medical and dental claims online.
- 3 to 5 years of related claims review, claims adjusting, insurance, benefits administration, or healthcare claims experience preferred for this level.
- Basic knowledge of group benefit plans and how plan benefits, eligibility, limitations, and exclusions relate to claims processing.
- Familiarity with HIPAA regulations, Health Care Reform requirements, medical terminology, CPT, ICD-9, ICD-10, diagnosis codes, and HCPCS codes.
- Ability to learn and use company and carrier computer systems for claims processing, data entry, and related responsibilities.
- Strong math skills, including the ability to recalculate claims and apply formulas using multiplication and percentages.
- Proficiency with office technology, including computers, ten-key calculator, photocopier, fax, spreadsheets, word processing, and data entry.
- Proficiency in Microsoft Word, Excel, and Outlook.
- Ten-key by touch skills and accurate data input ability.
- Excellent written and verbal communication skills.
- Strong analytical thinking, critical thinking, organization, and attention to detail.
- Ability to follow moderately complex oral and written instructions.
- Ability to sit at a desk and work on a computer for extended periods while maintaining focus, accuracy, and production standards.
- Ability to work effectively as part of a team and remain flexible with assigned duties.
- Must be able to complete claims examiner testing, cognitive and reading comprehension assessments, vocabulary assessment, and Microsoft Office proficiency testing.

Preferred Qualifications

- Experience using Anthem Blue Cross or similar carrier claims processing systems.
- Working knowledge of PPO guidelines, coordination of benefits, Medicare, and supplemental plan benefits.
- Prior experience supporting customer service functions related to eligibility, benefits, and claims inquiries.
- Experience working in a production-driven claims environment with quality and accuracy benchmarks.

Equal Opportunity Employer / Disabled / Protected Veterans

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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.

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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.