Summary: The Claims Examiner is responsible for ensuring claims are coded and processed correctly and for meeting production requirements. Processes claims by performing the following duties.


Essential Duties and Responsibilities include the following:


• Must be proficient in ICD-10, CPT, and HCPCS codes.
• Compare data on claim with internal policy and other company records to ascertain completeness and validity of claim.
• Comprehensive understanding of employee benefits for medical, dental and vision plans.
• Adjudicates medical claims, applies coordination of benefits as outlined in plan guidelines and works with providers to gather the necessary documents to make final payment determination on claims
• Ensures all claims are coded properly.
• Examines claim adjusters' reports or similar claims/precedents to determine extent of coverage and liability.
• Maintains high quality standards to avoid paying claim incorrectly.
• Maintains productivity standards set by Management.
• Refers most questionable claims for investigation to claim examiner II for review and processing.
• Research and resolve paid and denied claims escalations from internal sources and/or ticketing system when assigned.
• Works from the claims queue manager to process & releases claims for adjudication and payment within 3-5 days of receipt.
• Performs other duties and responsibilities as assigned by Management.
Supervisory Responsibilities: This job has no supervisory responsibilities.
Knowledge, Skills, & Abilities:
• Excellent written and verbal communication skills.
• Strong analytical skills and problem-solving skills.
• Must be dependable and maintain excellent attendance and punctuality
• Must be able to perform data entry operations quickly and accurately.
• Ability to grow with changing demands of the position and the company.
• Strong computer skills, including Word, Excel, and Outlook.
• Successful candidates must have experience processing medical claims for an insurance company or third-party administrator
• Must be proficient in ICD-10, CPT, and HCPCS codes.


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.