Claims Processor

TEKsystems•Fresno, CA

2d•$20 - $22•Remote

About The Position

We are seeking a detail-oriented Claims Processor I to join a growing healthcare organization. This role is responsible for reviewing, analyzing, and processing medical, dental, and vision claims while ensuring accuracy, compliance, and adherence to established production and quality standards. The ideal candidate will have experience in claims adjudication, medical terminology, and healthcare billing processes.

Requirements

High school diploma or equivalent.
1-3 years of healthcare claims processing experience or related industry experience.
At least 1 year of experience processing medical, dental, and vision claims.
Knowledge of claims adjudication and benefits determination.
Understanding of medical terminology and healthcare billing concepts.
Experience with UB-04, HCFA/CMS-1500 forms, ICD-10, CPT, and HCPCS coding.
Strong analytical, problem-solving, and decision-making skills.
Proficiency with Microsoft Office Suite, including Word, Excel, Outlook, and PowerPoint.
Strong data entry skills with the ability to accurately manage high-volume workloads.
Excellent written and verbal communication skills.
Ability to work independently in a fast-paced environment while maintaining quality standards.

Nice To Haves

Medical Billing Certification.
Medical Coding Certification.
Knowledge of ERISA claims processing guidelines.
Experience processing subrogation, accident, or third-party liability claims.
Experience working with CMS-1500 and HCFA claim forms.

Responsibilities

Review and adjudicate medical, dental, and vision claims in accordance with health plan guidelines and regulatory requirements.
Process inpatient, outpatient, physician, laboratory, radiology, accident, third-party liability (TPL), and Medicaid reclamation claims.
Analyze claim information to determine eligibility, benefits, pricing, prior authorization requirements, and coordination of benefits.
Research and resolve claim discrepancies using applicable documentation and plan guidelines.
Verify eligibility, authorizations, and supporting documentation to ensure accurate claim processing.
Contact healthcare providers as needed to obtain additional claim information.
Process Health Insurance Payment Demand (HIPD) claims.
Respond to inquiries from providers, customer service teams, member services, and internal departments.
Research and resolve correspondence related to paper and electronic claims.
Maintain compliance with HIPAA regulations and confidentiality requirements.
Meet established productivity, quality, and turnaround time standards.