Job Summary
We are seeking an experienced Claims Examiner for a temp-to-hire opportunity in Fremont, CA. This role is ideal for a detail-oriented insurance claims professional with current medical and dental claims processing experience, strong accuracy, and the ability to interpret group benefit plan provisions.
The Claims Examiner will work in a professional insurance and benefits administration environment where quality, consistency, and customer care are essential. This opportunity offers the chance to contribute to a collaborative team, build deeper expertise in claims systems and benefit plan administration, and work with supportive leadership focused on accuracy, training, and operational excellence.
Key Responsibilities
- Process medical and dental claims accurately using online claims systems and applicable carrier platforms.
- Interpret group benefit plan documents, including eligibility, benefits, limitations, exclusions, PPO guidelines, coordination of benefits, Medicare, and supplemental plan provisions.
- Communicate professionally with providers and participants by phone, email, fax, correspondence, or in person regarding claims, eligibility, and benefit questions.
- Maintain accurate documentation of calls, requests, claim activity, and benefit inquiries in applicable systems.
- Recalculate claims as needed using formulas, percentages, multiplication, and other benefit-related calculations.
- Support auditors, managers, training sessions, staff meetings, and additional department needs as assigned.
Compensation and Benefits
- Pay: $40 to $41.85 per hour.
- Employment Type: Temp-to-Hire.
- Location: Fremont, CA.
Equal Opportunity Employer / Disabled / Protected Veterans
The Know Your Rights poster is available here:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf
The pay transparency policy is available here:
https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf
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.
https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf
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.
Required Qualifications and Skills
- Process medical and dental claims online with accuracy and attention to plan requirements.
- Interpret benefit plans, eligibility rules, exclusions, limitations, PPO guidelines, coordination of benefits, Medicare, and supplemental plan provisions.
- Communicate with providers and participants while maintaining complete and accurate records.
- Perform claim recalculations and support department audits, service needs, and production goals.
- Minimum of two years of current medical and dental claims processing experience.
- Basic knowledge of group benefit plans and how plan benefits, eligibility, limitations, and exclusions relate to claims processing.
- Familiarity with HIPAA regulations, Health Care Reform requirements, medical terminology, CPT, ICD-9, ICD-10, diagnosis codes, and HCPCS codes.
- Ability to learn and use company and carrier computer systems, including Anthem Blue Cross systems.
- Strong ten-key by touch skills, word processing ability, data entry accuracy, and general office equipment proficiency.
- Ability to perform detailed claim calculations using multiplication, percentages, and formulas.
- Excellent written and verbal communication skills.
- Strong analytical thinking, critical thinking, organization, and time management skills.
- Ability to follow moderately complex oral and written instructions.
- Detail-oriented, flexible, team-focused, and able to maintain production standards while meeting quality expectations.
- Ability to sit at a desk and use a computer for extended periods while maintaining concentration and accuracy.
Preferred Qualifications
- Experience with Anthem Blue Cross claims systems.
- Prior experience supporting customer service inquiries related to eligibility, benefits, and plan document interpretation.
- Experience working in a benefits administration, insurance, third-party administrator, or group health plan environment.