Healthcare Claim Processor

As a Medi-Cal Claims Examiner, you will be responsible for reviewing, processing, and adjudicating suspended healthcare claims to ensure accurate and timely payment. You will apply Medi-Cal policies, regulations, and reimbursement guidelines while evaluating member eligibility, provider information, authorizations, benefits, and supporting documentation. This role is ideal for a detail-oriented professional who enjoys analyzing claims, resolving issues, and working in a fast-paced healthcare environment while maintaining a high standard of accuracy and confidentiality.

Review and adjudicate suspended claims to ensure accurate processing and payment in accordance with established guidelines.
• Confirm member eligibility, provider information, required authorizations, and covered benefits.
• Evaluate medical records, claim forms, billing details, and supporting documentation to determine appropriate claim outcomes.
• Identify discrepancies and resolve claim errors to ensure accurate adjudication.
• Investigate and resolve claims-related issues while meeting established quality, productivity, and turnaround-time standards.
• Apply Medi-Cal policies, regulations, reimbursement rules, and payment guidelines consistently and accurately.
• Analyze claim information and interpret applicable policies and procedures to determine the appropriate resolution.
• Safeguard protected health information and maintain compliance with HIPAA and organizational confidentiality requirements.
• Partner with internal teams to address complex claims issues and escalate matters requiring additional review or resolution.
• Accurately document claim reviews, actions taken, and final adjudication decisions in the appropriate systems