Claims Examiner I

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.

What You’ll Do

• 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 You Bring

• 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
• Experience with Facets (preferred)
• 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

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you and excellent customer service for our members.