Phone: 877-4MED-123 / 877-463-3123
June 26th, 2017

Job Description and Qualifications

Claims Examiner

Review and enter claim information data from the claim form into the computer system.
Review and correct claim data fields as appropriate and necessary. Review and defer claims requiring additional research. Meet quality, accuracy and turn-around standards for claims by verifying and entering the correct information daily.

Adjudicate medium complexity medical claims such as fee for service, in timely and accurate manner. Consistently and accurately adjudicate all complex contracted claims with fee-for-service carve outs, professional and hospital claims for non-contracted provider and contracted hospital claims for both Commercial and Senior plans within the timeliness and accuracy standards set forth by CMS, Department of Managed Care, AB1455 and the Claims Department policies and procedures.

Member Services Specialist

Responsible for eligibility and benefit verification and collection of medical data needed for utilization management. Coordinates the review and approval process for inpatient and outpatient hospital services, ambulatory medical imaging, diagnostic testing, durable medical equipment, home health care, and cost of medications. Functions as a resource for other licensed and non-licensed staff. Assists in the delivery of high quality, cost effective health care services for members.

Apply for available Claims Services / Member Services Positions by emailing your resume at