Claims Examiner I

Job Description

Claims Examiner I

Are you a recent graduate with a Medical Billing or Coding certification or degree looking to kickstart your career? TEKsystems is seeking a motivated Claims Examiner I to join our team in Fresno, CA. While no prior professional experience as a Claims Examiner is required, a recent and relevant certification or degree is a must. This is a fantastic opportunity for individuals eager to apply their foundational knowledge in a dynamic healthcare environment.

About the Role

The Claims Examiner I, reporting directly to the Supervisor of Claims, plays a crucial role in ensuring the accurate and timely processing of medical, dental, and vision claims. This position requires meticulous attention to detail and adherence to state, federal, and health plan regulatory requirements, as well as department guidelines. You will be responsible for meeting established quality and production performance benchmarks through thorough research and review of applicable documentation, including processing Health Insurance Payment Demand (HIPD) claims. The role involves in-depth review, analysis, and research of healthcare claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. You will also assist in resolving issues escalated from providers, customer service, member services, health plans, and other internal stakeholders.

Key Responsibilities

• Review and process medical, dental, vision, and electronic claims in compliance with state, federal, and health plan regulatory requirements and department guidelines.
• Meet established quality and production performance benchmarks.
• Conduct research and review applicable documentation for claim adjudication.
• Process Health Insurance Payment Demand (HIPD) claims.
• Thoroughly review, analyze, and research health care claims to identify discrepancies, verify pricing, and confirm prior authorizations.
• Process claims for payment.
• Assist in resolving issues from providers, customer service, member services, health plan, and other internal customers.
• Examine problems, data, or text, considering multiple sides of an issue and weighing consequences before making decisions.
• Ensure compliance with all appropriate policies and practices, as well as local, State, and Federal regulations and requirements regarding claims and contract administration.
• Partner with peers to document and analyze functional requirements, identify gaps, and propose alternative approaches to resolve problems.
• Contribute to defining and documenting standards, periodically reviewing them to integrate appropriate industry standards.
• Alert supervisors to potential higher-risk compliance issues.
• Make timely and effective decisions based on available information.
• Recognize issues, analyze, solve problems, research, identify trends, and determine actions needed to advance the decision-making process within a realistic timeframe, including necessary follow-up.
• Involve appropriate personnel in defining, understanding the impact of, and resolving problems.

Required Skills & Qualifications

• MUST HAVE A RECENT MEDICAL BILLING OR CODING CERTIFICATION/DEGREE.
• High school education or equivalent.
• Basic knowledge of medical terminology.
• Familiarity with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
• Good verbal and written communication skills.
• Proficient in 10-key by touch data entry and able to type 40 WPM.
• Proficient in Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess the capability to quickly learn new applications.
• Ability to work under pressure and adapt to a changing environment.
• Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.
• Minimum one (1) to three (3) years of experience as a Health Claims Examiner or comparable industry experience is preferred, though not strictly required given the certification/degree mandate.
• A minimum of one (1) year experience as a Claims Examiner for medical, dental claims, vision, subrogation, and accident claims is preferred.
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination.

Experience Level

Intermediate Level

Job Type & Location

• Job Type: Contract position
• Location: Fresno, CA (Hybrid workplace)

Pay and Benefits

• Pay Range: $20.00 – $22.00/hr
• Benefits: Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
  • Medical, dental & vision
  • Critical Illness, Accident, and Hospital
  • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
  • Life Insurance (Voluntary Life & AD&D for the employee and dependents)
  • Short and long-term disability
  • Health Spending Account (HSA)
  • Transportation benefits
  • Employee Assistance Program
  • Time Off/Leave (PTO, Vacation or Sick Leave)

Application Deadline

This position is anticipated to close on April 15, 2026.

About TEKsystems

We’re partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That’s the power of true partnership. TEKsystems is an Allegis Group company.

We’re a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We’re a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We’re strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We’re building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.