Claims Examiner Pharma Operations 100% Remote In Pacific Time

BCforward is currently seeking a highly motivated Claims Examiner for an opportunity in 100% Remote - California / PST





Job Title: Claims Examiner (Operations) I

Location: 100% Remote - California / PST

Duration: 6-Month Contract and Possible of extension or conversation FTE

Schedule: Monday–Friday, 8:00 AM–5:00 PM PST

Pay Rate: $23/hr on W2



Position Summary


- Process routine pharmacy and medical claims to determine eligibility, reimbursement, and benefit payment.
- Review claims for accuracy and ensure processing meets quality, productivity, and department standards.
- Determine reimbursement based on established criteria, provider contracts, health plan provisions, and employer group benefits.
- Match authorizations to claims and research missing or required information.
- Review appeals and complaints and investigate issues requiring additional information or resolution.
- Research and resolve claim issues involving Coordination of Benefits (COB), dual coverage, Medicare secondary payor, prior insurance, out-of-network services, prior authorizations, Medi-Cal, Veterans Administration, and other complex claim scenarios.
- Perform combined pharmacy/medical accumulator reviews and audits.
- Review and audit EOBs for multiple health plans.
- Verify prescription copay card usage for brand medications.
- Process and update member eligibility information.
- Contact pharmacies to verify drug information and prescription copay card usage.
- Provide phone support to exchange members and respond to inquiries from providers, members, and internal departments.
- Maintain current procedural and reference materials and follow established department guidelines.


Required Qualifications


- High School Diploma/GED or higher education required.
- Minimum 6 months of claims examining experience OR completion of a technical claims-processing course.
- Pharmacy or medical claims processing experience required.
- Experience working with Microsoft applications preferred.
- No license required.


Preferred Qualifications


- Pharmacy Technician experience.
- Medical billing experience.
- California Pharmacy Technician License preferred.
- Strong customer service and telephone experience.






Benefits:

BCforward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.



About BCforward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward’s 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCforward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.