• Claims Specialist

    Job Locations US-CA-Fairfield
    Job ID
  • Overview

    To support the Claims Department in maintaining pended claims and claim adjustments within established guidelines. Reviews and processes complex claims, and supports claims examining.


    • Researches and processes claim adjustment requests.
    • Participates in special claim adjustment projects as assigned.
    • Assists in maintaining pended claim reports and files within established department guidelines and program policies.
    • Performs claims examining functions as assigned.
    • Performs claims customer service functions as assigned.
    • Assists in training claims staff as needed.
    • Monitors efficiency of operations and provides feedback to management on possible effective procedure changes.
    • Records daily production statistics and related activities on appropriate reports; turns all logs and reports into the Claims Supervisor.
    • Other duties as assigned.


    Education and



    Minimum three (3) years claims examining experience; or PHC claims examining experience and completion of PHC claims training; or equivalent combination of education and experience; College course work in business or related field preferred.




    Special Skills,

    Licenses and




    Familiarity with Medi-Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding. Knowledge of PHC Claim Policy and Procedures, EDS provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals. Typing speed 30 wpm and proficient use of 10-key calculator. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.









    Excellent oral and written communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes with conflicting priorities. Good organizational skills with ability to maintain accurate records and documentation of actions and decisions.




    Work Environment

    And Physical Demands



    Ability to use a computer keyboard; more than 80% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 25 lbs. Ability to attend off-site meetings as required.





    Additional Preferred Skills:  Strong analytical and problem solving skills, ability to multi-task and meet deadlines. Excellent organizational and communication skills.


    All HealthPlan employees are expected to:


    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees 
    • Maintain safe practices; and
    • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.




    The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.





    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed