Claims Examiner I (Operations) - (Rancho Cordova, CA)

HourlyPosition Purpose: Under close supervision, this position processes routine claims within a single product line to determine type and amount of benefit payable. Performs limited duties, subject to review and approval, for the processing of such claims assigned, consistent with applicable policies, procedures and department guidelines. Determines level of reimbursement based on established criteria, provider contract, plan and employer group provisions. Processes all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specification. Matches authorizations to claims, maintains current desk procedural and reference materials. Reviews appeals and complaints; researches any missing or required details. Responds by telephone or in writing to providers, members, or other company departments to process and resolve the claim issue.