Claims Examiner I

Western Health Advantage • Sacramento, CA

3d • $20 - $21 • Hybrid

About The Position

As a Claims Examiner I, you’ll play a vital role in delivering on that promise by reviewing and adjudicating medical claims with precision, integrity, and timeliness. If you’re detail-oriented, thrive in a fast-paced environment, and want to contribute to a mission-driven organization, this is an opportunity to grow your career while making a meaningful difference.

Requirements

• High school diploma or equivalent
• At least 1 year of experience in healthcare claims adjudication (HMO experience preferred)
• Knowledge of ICD, CPT, and Revenue Codes
• Solid computer skills, including Microsoft Office and database systems
• Strong attention to detail and ability to interpret complex information
• Effective communication skills and ability to work collaboratively

Nice To Haves

• Experience with Facets (preferred)

Responsibilities

• Review and analyze medical claims to determine accurate payment or denial based on coding, contracts, and Division of Financial Responsibility (DOFR) guidelines
• Adjudicate claims in compliance with internal policies and regulatory standards
• Process claims and apply adjustments with a high level of financial and procedural accuracy
• Handle member reimbursement claims while meeting strict turnaround timelines
• Maintain strong audit performance and quality standards
• Ensure timely routing of misdirected claims to the appropriate payer
• Meet key turnaround requirements, including: Risk claims acknowledgment within 15 business days Commercial claims finalized within 45 business days ERISA claims finalized within 30 days Clean claims processed within 30 calendar days Unclean/contracted claims resolved within 60 calendar days
• Consistently meet productivity, accuracy, and timeliness expectations
• Contribute to team initiatives and support special projects as needed

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED