Medical Insurance Claims

Job Summary

We are seeking a detail-oriented Medical Insurance Claims professional for a full-time temp-to-hire opportunity in Bakersfield, CA. This hybrid/remote role is ideal for a claims processing professional with payer-side or health insurance claims experience, rather than clinic-only billing experience.

In this role, you will review, process, audit, and resolve medical and facility claims for payment while applying contract benefits, policies, procedures, eligibility rules, coding guidelines, and payment standards. You will support accurate, timely, and compliant claims administration within a mission-driven healthcare services environment focused on improving member health.

This is a strong opportunity for someone who enjoys focused claims review work, values accuracy, and wants to grow within a stable healthcare organization. The team environment supports collaboration, clear processes, professional development, and access to leadership guidance on more complex claims. This position may be filled at the I or II level based on experience and qualifications.

Key Responsibilities

- Review and process medical and facility claims from contracted and non-contracted providers, subscribers, and enrollees.
- Resolve system-suspended claims for PCPs, labs, radiology, less complex specialists, and physical therapy claims.
- Apply benefits, contract terms, claims policies, coding guidelines, and payment procedures accurately and timely.
- Identify billing errors, possible fraudulent submissions, overpayments, CCS eligibility issues, COB concerns, and claims requiring additional review.
- Deny inappropriate claims according to policy guidelines and route complex claims to the appropriate department or supervisor.
- Maintain productivity, quality, documentation, and attendance standards in accordance with department guidelines.

Equal Opportunity Employer / Disabled / Protected Veterans

The Know Your Rights poster is available here:

The pay transparency policy is available here:

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.

AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.

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.

Additional Skills

Required Qualifications and Skills

- Process medical insurance claims from the payer, health plan, HMO, or insurance perspective.
- Review suspended, denied, routed, and manually calculated claims for accuracy.
- Investigate eligibility, coordination of benefits, other health coverage, and potential overpayment issues.
- Apply medical claims policies, contract benefits, coding, and payment guidelines.

- High school diploma from an accredited school or equivalent required.
- 1 to 2 years of medical claim payment or medical billing processing experience required.
- Experience processing claims for medical insurance, health plans, HMOs, or payer-side claims operations required.
- Experience must include claims processing from the medical insurance side, not only clinic-based billing.
- Experience investigating coordination of benefits.
- Ability to calculate usual and prevailing fees.
- Knowledge of computerized online data entry systems and medical claims processing workflows.
- Knowledge of medical terminology, HCPCS, CPT, ICD-10 coding, UB04 forms, and CMS1500 forms.
- Ability to identify billing errors, possible fraud indicators, CCS eligibility issues, and claims requiring additional review.
- Must have access to a Windows 11 computer for system compatibility when working in a hybrid/remote arrangement.
- Strong attention to detail, accuracy, organization, and follow-through.
- Ability to work independently in a rapidly changing environment.
- Strong communication skills for working with internal teams, providers, and other healthcare contacts.

Preferred Qualifications

- Health maintenance organization claims payment processing experience.
- Knox-Keene licensed HMO claims payment or claims auditing experience.
- Strong knowledge of claims auditing, payment accuracy, and healthcare compliance procedures.