Claims ExaminerAppleOne

AppleOne, a division of the Act-1 Group, is proud to present:

Job Summary

We are seeking a detail-oriented Claims Examiner for a direct hire opportunity in Fremont, CA. This role is ideal for a medical and dental claims professional with strong accuracy, analytical ability, and experience processing claims in a fast-paced insurance or benefits administration environment.

The Claims Examiner will review, interpret, and process group benefit claims while ensuring plan documents, eligibility rules, limitations, exclusions, HIPAA requirements, and applicable coding standards are followed. This is a strong opportunity for someone who enjoys structured work, clear production goals, supportive team collaboration, and the ability to build deeper expertise in claims systems, benefit plans, and healthcare reimbursement processes.

Key Responsibilities

- Process medical and dental claims accurately using online claims systems and applicable carrier platforms.
- Interpret group benefit plan documents, eligibility, limitations, exclusions, PPO guidelines, coordination of benefits, Medicare, and supplemental plan benefits.
- Recalculate claims using formulas, percentages, multiplication, and detailed benefit provisions to ensure accurate payment outcomes.
- Communicate professionally with providers and participants by phone, email, correspondence, fax, or in person regarding eligibility, benefits, and claim-related questions.
- Maintain accurate documentation of calls, eligibility requests, benefit inquiries, and claim activity.
- Assist auditors, managers, and team members with claims research, documentation, reporting, and other assigned duties.

Compensation and Benefits

- Salary: $87,048 per year.
- Job Type: Direct Hire.
- Location: Fremont, CA.