Healthcare Claim Processor

OVERVIEW

Who We Are:

Qualfon is a global provider of omnichannel customer experience and business support solutions. From call center support to lead generation to ecommerce fulfillment, we support our clients and their customers throughout the customer journey.

Our mission is to help as many people as possible pursue their total vocation - as individuals and as members of society by creating an ever-growing number of job opportunities as we strive to become the partner of choice for our clients.

At Qualfon, you'll find more than just a job, you'll find a place to grow, develop your career, and be part of a supportive, purpose-driven team.

RESPONSIBILITIES

What You'll Do:

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

QUALIFICATIONS

What You'll Bring:

• At least two (2) years of experience in Medicaid/Medi-Cal claims processing and adjudication.
• Working knowledge of healthcare claims, medical terminology, and billing practices.
• Familiarity with CPT, HCPCS, and ICD-10 coding principles.
• Strong attention to detail and a commitment to maintaining accuracy while meeting productivity and turnaround-time expectations.
• Ability to understand, interpret, and apply policies, procedures, regulatory requirements, and payment guidelines.
• Strong analytical, organizational, and time-management skills with the ability to prioritize competing tasks.
• Ability to perform effectively in a high-volume, fast-paced production environment.
• Excellent verbal and written communication skills.
• Ability to independently research, analyze, and resolve claims issues using established guidelines and resources.
• Proficiency with claims processing systems, Microsoft Office, and other computer-based applications.
• Demonstrated ability to protect confidential information and appropriately handle sensitive member and provider data.

EEO Statement

QUALFON is an equal opportunity employer. QUALFON provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity, national origin, age, disability, genetic information (including testing and characteristics), marital status, ancestry, status as a covered veteran, uniformed servicemember status and any other characteristic protected under applicable federal, state or local law.

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