Payer-Side Claims Processing

Now hiring experienced Medical Claims Examiners with PAYERS SIDE claims processing experience is REQUIRED.

We are seeking detail-oriented professionals with experience reviewing, auditing, and adjudicating medical claims in a health plan, insurance carrier, managed care, HMO, Medicare, Medicaid, or payer environment. Candidates must have working knowledge of CPT, HCPCS, ICD-10 coding, Coordination of Benefits (COB), and medical claim forms including UB-04 and CMS-1500.
Payer-side claims experience is REQUIRED and is NOT negotiable.

This is a temporary hybrid/remote opportunity based in Bakersfield, CA offering competitive hourly pay and the opportunity to work with a leading healthcare Client

Required Qualifications

-High School Diploma or equivalent

-Minimum 1–2 years of medical claims processing

-Experience on the payer side Experience adjudicating claims for a health plan, insurance carrier, managed care organization, HMO, Medicare, Medicaid, or third-party administrator -Experience investigating and resolving Coordination of Benefits (COB) issues
-Experience reviewing professional and facility claims for payment accuracy
-Ability to calculate usual, customary, prevailing, or contract-based reimbursement rates

Required Knowledge
-Medical terminology
-CPT, HCPCS, and ICD-10 coding
-UB-04 and CMS-1500 claim forms
-Eligibility verification and insurance coverage review
-Claims auditing and payment determination
-Managed care and HMO claim processing

Computer Skills
-Claims processing systems
-Online eligibility verification tools
-Data entry platforms
-Microsoft Outlook, Word, and Excel
-Ability to navigate multiple systems while maintaining productivity and accuracy

Important Requirement
This position requires recent payer-side medical claims processing experience. Candidates with provider-side billing only experience will not be considered.

Equal Opportunity Employer / Disabled / Protected Veterans

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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.

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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

Responsibilities

Review, audit, and process medical and facility claims accurately and within established service levels

Apply contract benefits, policies, and payment guidelines

Resolve suspended and pended claims involving:

-Primary Care Providers (PCPs)

-Laboratory services

-Radiology services

-Physical Therapy services

-Specialist claims

Investigate and resolve Coordination of Benefits (COB) issues

Verify member eligibility and other insurance coverage

Identify billing errors, inconsistencies, and potential fraudulent claim activity

Calculate benefits and reimbursements when manual review is required

Deny claims according to policy and contractual guidelines

Route complex claims to appropriate departments for further review

Maintain productivity and quality standards

Ready to put your payer-side claims experience to work?

Apply today if you have experience processing medical claims for a health plan, insurance carrier, managed care organization, HMO, Medicare, Medicaid, or other payer environment.
Candidates with strong CPT, HCPCS, ICD-10, COB investigation, and medical claims adjudication experience are encouraged to apply immediately.
Payer-side claims processing experience is required.
Document findings and overpayment requests accurately

Collaborate with internal teams to resolve claim discrepancies
Ready to put your payer-side claims experience to work?
Apply today if you have experience processing medical claims for a health plan, insurance carrier, managed care organization, HMO, Medicare, Medicaid, or other payer environment.
Candidates with strong CPT, HCPCS, ICD-10, COB investigation, and medical claims adjudication experience are encouraged to apply immediately.
Payer-side claims processing experience is required.