Medicare Claims Examiner

Medicare Claims Examiner (D-SNP) | 100% Remote | California Residents Only

Cen Cal Health is seeking an experienced Medicare Claims Examiner to join their team in a fully remote position. This is an excellent opportunity for candidates with a strong background in Medicare claims processing, D-SNP plans, and health plan operations.

Important:
Candidates must reside in California and have hands-on QNXT experience. QNXT is a required qualification and candidates without QNXT experience will not be considered.

• Review, research, price, and process paper and electronic claims
• Research and resolve pended and denied D-SNP claims
• Determine claim payment eligibility and accurately adjudicate claims
• Review manual review and audit reports
• Maintain documentation related to CPT, HCPCS, ICD, and HCFA coding
• Ensure compliance with Medicare, Medi-Cal, CMS, and health plan guidelines
• Communicate with internal departments regarding claim issues and resolutions
• Identify trends and support process improvement efforts
• Meet productivity, quality, and turnaround-time expectations

• 3+ years of Claims Examiner or healthcare claims processing experience
• Medicare and/or Medi-Cal claims processing experience
• D-SNP (Dual Eligible Special Needs Plan) experience
• Health plan experience
• Strong understanding of claims adjudication and payment determination
• Experience working in a high-volume production environment
• Knowledge of CPT, HCPCS, ICD, and HCFA coding
• Medical terminology knowledge
• Strong analytical, organizational, and communication skills
• Ability to work independently in a remote environment
• Proficiency with Microsoft Office and claims processing systems

• QNXT experience is required
• Medicare Advantage and/or D-SNP experience is required
• Health plan experience is required
• Must currently reside in California
• Must be comfortable working in a production-driven environment

• 100% Remote
• Equipment provided by Cen Cal Health
• Contract opportunity with potential for extension based on performance and business needs

This is a Contract position based out of Long Beach, CA.

The pay range for this position is $28.50 - $30.50/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)

This position is anticipated to close on Oct 29, 2026.

This is a fully remote position.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

San Francisco Fair Chance Ordinance:
Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector:
It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI):
We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess…