Medical Claims Examiner

Job Summary

We are seeking a detail-oriented Medical Claims Examiner for a temp-to-hire opportunity in Fremont, CA. This role is ideal for a claims professional with hands-on medical claims adjudication experience who can review, analyze, process, and finalize healthcare claims accurately and efficiently.

The Medical Claims Examiner will work in a production-focused administrative and claims processing environment where accuracy, compliance, and timely turnaround are essential. This opportunity offers the chance to contribute to a quality-driven team, work with supportive leadership, and apply your knowledge of healthcare benefits, medical billing, and claims guidelines in a role with long-term potential.

The ideal candidate understands the full medical claims lifecycle and can independently determine claim payment, denial, adjustment, or the need for additional information.

Key Responsibilities

- Review, process, and adjudicate medical claims in accordance with plan benefits, provider contracts, policies, and regulatory requirements.
- Evaluate claims for eligibility, coverage, coding, authorization requirements, duplicate billing, missing information, and coordination of benefits.
- Determine appropriate payment, denial, adjustment, reconsideration, or reprocessing actions based on claims guidelines.
- Calculate allowable amounts, member responsibility, deductibles, copays, coinsurance, and other applicable benefit provisions.
- Research complex or incorrectly processed claims, document actions taken, and escalate issues when additional review is required.
- Maintain confidentiality of member and healthcare information while meeting productivity, accuracy, quality, and turnaround-time standards.

Compensation and Benefits

- Compensation: $87,048 per year.
- Employment type: Temp-to-hire.
- Location: Fremont, CA.
- Benefits: Not specified.

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.

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

- Review and adjudicate medical claims from initial analysis through final disposition.
- Interpret benefit plans, provider contracts, claims policies, and healthcare billing information.
- Research claim discrepancies and determine accurate payment, denial, adjustment, or additional action.
- Process claim corrections, reconsiderations, adjustments, and reprocessing requests.

- 1 to 2 years of relevant experience preferred, with previous hands-on medical claims adjudication experience required.
- Previous medical claims processing experience required.
- Strong understanding of healthcare benefits, eligibility, claims terminology, and medical billing.
- Familiarity with CPT, HCPCS, ICD-10, EOBs, deductibles, copays, coinsurance, and coordination of benefits.
- Ability to independently review claims and make accurate adjudication decisions.
- Experience interpreting benefit provisions, policies, contracts, and claims-processing guidelines.
- Strong attention to detail, numerical accuracy, analytical thinking, and problem-solving ability.
- Ability to work in a production-driven environment while maintaining quality standards.
- Proficiency with claims-processing systems and Microsoft Office.
- Knowledge of HIPAA and healthcare confidentiality requirements.
- Strong organizational skills and the ability to communicate effectively with internal teams, providers, and other stakeholders.

Preferred Qualifications

- Experience processing claims for a Third-Party Administrator, health plan, insurance carrier, or self-funded benefits environment.
- Experience with high-volume medical claims processing.
- Experience handling complex, adjusted, denied, reconsidered, or appealed claims.
- Familiarity with provider contracts and reimbursement methodologies.
- Experience beyond claims intake, data entry, customer service, or claims status inquiries.