Claims Specialist

TEKsystems • Los Angeles, CA

3d • Onsite

About The Position

We’re hiring a Claims Specialist to support healthcare claims compliance and adjudication operations within a high‑volume environment. This role focuses on claims review, authorization validation, denials processing, and compliance auditing, ensuring claims are processed accurately and in alignment with HMO and Medicare guidelines. If you have strong experience with EZCAP, HMO claims, and authorization workflows, this is a high‑impact role where your expertise will matter.

Requirements

• Strong experience with HMO Claims
• Experience in Claim Denials and authorization review
• Hands‑on experience using EZCAP or similar claims systems
• Knowledge of Medicare Claims and payer guidelines
• Solid understanding of claims workflows and adjudication standards
• 5+ years of experience in claims processing, claims analysis, or claims compliance
• Ability to collaborate with leadership and cross‑functional teams on process improvements
• Strong analytical skills with attention to detail in high‑volume claims environments

Nice To Haves

• Knowledge of CPT Codes
• Excel proficiency for tracking, reporting, or auditing
• Familiarity with Medicare Guidelines
• Experience in claims audits or compliance review
• Experience with system configuration or workflow optimization preferred

Responsibilities

• Review institutional and professional claims to validate authorization requirements and payer contracts
• Determine whether existing authorizations can be used to process claims and update EZCAP accordingly
• Prepare claims for administrative denial when appropriate and route back to examiners
• Perform case follow‑up with Medical Directors and update case status (approx. 216 active cases)
• Review claims for sensitive services and special cases, including Guardant claims, validating authorization via REA
• Track, analyze, and document claim outcomes, identifying trends and potential compliance risks
• Support claims audits, resubmissions, and special projects tied to operational and system improvements

Benefits

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 501-1,000 employees