Claims Examiner I

Job Description

Claims Examiner I | TEKsystems

The Tone:
This is a contract role at TEKsystems, located in Fresno, CA, with a hybrid workplace model. TEKsystems is an industry leader in Full-Stack Technology Services and Talent Services, partnering with clients to activate ideas and solutions for business transformation. This role is crucial for ensuring the accurate and timely processing of various medical, dental, and vision claims, directly supporting healthcare operations and compliance for our clients.

The TL;DR
• Role: Contract
• Type: Contract position
• Location: Hybrid; Fresno, CA
• Pay: $20–$22 hourly
• Team: Reports directly to the Supervisor of Claims.
• Mission: To accurately and timely process medical, dental, and vision claims while adhering to state, federal, and health plan regulatory requirements.
• Tech Stack: Microsoft Office (Word, Excel, Outlook, PowerPoint); UB-04, HCFA 1500 forms (837/5010 format), ICD10, CPT, HCPCS codes.

What You’ll Actually Do
• Claim Processing: Review and process medical, dental, vision, and electronic claims in compliance with state, federal, and health plan regulatory requirements and department guidelines.
• Performance Benchmarking: Meet established quality and production performance benchmarks through thorough research and review of applicable documentation.
• Claim Analysis: Thoroughly review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment.
• Issue Resolution: Assist in resolving issues escalated from providers, customer service, member services, health plans, and other internal stakeholders.
• Compliance Assurance: Ensure compliance with all appropriate policies and practices, as well as local, State, and Federal regulations and requirements regarding claims and contract administration.

The Must-Haves
• Background: Recent graduate with a Medical Billing or Coding certification or degree; High school education or equivalent with basic knowledge of medical terminology.
• Experience: 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 also preferred.
• Skills: Familiarity with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes; Proficient in 10-key by touch data entry and able to type 40 WPM; Proficient in Microsoft Office (Word, Excel, Outlook, PowerPoint) and capable of quickly learning new applications.
• Bonus: Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines; Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and/or benefit determination.