Description We are on the lookout for a dedicated Medical Claims Representative based in Rancho Cordova, California. As a Medical Claims Representative, your primary role will be to review and process claims from out-of-group providers, ensuring compliance with company policies, health plan contracts, and other relevant regulations. This opportunity offers a long-term contract employment in the healthcare industry.

Responsibilities:

• Review and process claims from Out of Group providers, adhering to written criteria, policies, and procedures.

• Determine the appropriateness of claims for payment, considering factors such as eligibility, benefits, authorizations, coding, and contracted payment terms.

• Stay up-to-date with changes in contracts annually and apply the correct terms to the claims.

• If a claim is not appropriate for payment, ensure that the denial is correctly executed in the system for the letter to print accurately.

• Consistently meet internal, external, and governmental timeliness standards.

• Maintain the discretion to pay or deny medical services using the department's policy guidelines.

• Handle sensitive and confidential information with discretion and professionalism.

• Refer claims and documentation that do not meet our department policy guidelines to the UM department as needed.

• Maintain communication with Eligibility, Member Services, UM, providers, the Health Plans, and any applicable staff as required.

• Ensure the achievement of production and quality standards.

• Work independently on assigned tasks and activities, based on established policies and procedures. Requirements • Proficiency in Allscripts software

• Experience with Cerner Technologies

• Familiarity with EHR SYSTEM

• Expertise in handling appeals

• Proficiency in executing billing functions

• Experience in claim administration

Robert Half is the world’s first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app (https://www.roberthalf.com/us/en/mobile-app) and get 1-tap apply, notifications of AI-matched jobs, and much more.

All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.

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