At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option to the most vulnerable senior population, while serving as a care provider and care plan to those individuals we serve.

Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Senior Claims Examiner plays a pivotal role in ensuring timely and efficient processing of claims for our contracted specialty provider partners.

Essential Job Duties:

• Examine claim records and forms to investigate and resolve first level disputes, including completion of acknowledgement and determination letters
• Review and process second level claims, such as adjustments and corrected claims
• Work closely with leadership on identified trends related to improper processing and claim-related concerns or discrepancies that result in a dispute
• Assist the team in carrying out departmental responsibilities and collaborate with others to support short- and long-term goals and priorities
• Establish and maintain effective working relationships with team and collaboration with interdepartmental staff and leadership
• Work closely with leadership on identified trends related to improper processing and claim related concerns or discrepancies that result in a dispute

Job Requirements:

• Minimum of three (3) years’ health plan claims processing experience, and two (2) years’ health plan claims dispute experience analyzing and resolving provider claims problems
• Experience in a Managed Care Plan (MCP) or PACE organization (PO) claims processing environment highly preferred
• In depth experience with Medicare and Medicaid claims processing
• Strong computer and appropriate software knowledge (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word, Teams) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the 
  position
• Ability to balance competing priorities, exercise discretion, and consider all relevant factors in navigating gray areas and resolving ambiguities
• Proficient in the principles and practices of managed health care, health care systems and medical terminology (e.g., revenue Codes, Current procedural Terminology (CPT), Healthcare Common Procedure Coding system (HCPCS) and Internal Classification of Disease (ICD-10)
• Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee schedule and Diagnosis Related Groups (DRG) and benefit interpretation and administration

Benefits of Working at WelbeHealth: Apply your claims expertise in meaningful ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• Medical insurance coverage (Medical, Dental, Vision) 
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days
• Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
• And additional benefits

At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option to the most vulnerable senior population, while serving as a care provider and care plan to those individuals we serve.

Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Claims Examiner plays a pivotal role in ensuring timely and efficient processing of claims for our contracted specialty provider partners.

Essential Job Duties:

• Examine, review and process claims according to contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Assess appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards
• Ensure claim timeliness processing standards are being met
• Work alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements
• Assist internal and external partners with questions related to claims decisions or claims statuses
• Maintain a comprehensive understanding of claim processing guidelines at both the federal and state level

Job Requirements:

• High School Diploma or Equivalency, professional experience may be substituted
• Minimum of three (3) years of experience with processing, researching, and adjudicating claims in a complex managed care environment
• Working knowledge of the health plan insurance industry and CPT/HCPCS procedure codes, and relevant federal and state regulations
• Understanding of Industry pricing methodologies, such as Medicare/Medi-Cal fee  schedule, Diagnosis Related Groups (DRG), Multiple Procedure Payment Reduction (MPPR) and benefit interpretation and administration 
• In depth experience with Medicare and Medicaid claims processing
• Demonstrated skills within Microsoft Office Applications & electronic claims processing systems
• Strong organizational, analytical, communication, and time management skills

Benefits of Working at WelbeHealth: Apply your claims expertise in meaningful ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time
• Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
• And additional benefits

At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option (PACE) to the most vulnerable senior population while serving as a care provider and care plan to those individuals we serve.

Our Health Plan Services team helps ensure excellent care delivery for our participants, and the Claims Audit Analyst plays a pivotal role in ensuring timely and accurate pre-payment or denial of claims while meeting federal/state regulations, provider agreements terms, and/or company policies and procedures.

Essential Job Duties:

• Review processed claims for accuracy prior to payment while maintaining acceptable levels of claim’s aged inventory by verifying various aspects of the system and claim
• Complete and maintain detailed documentation of audit findings which include decision methodology, system or processing errors, and monetary discrepancies
• Move claims free of processing errors through for full adjudication and return claims with errors back to the claims team for corrections
• Provide feedback to the Oversight & Monitoring Manager on claims processing errors, quality improvement opportunities, and configuration change requests, when applicable

Job Requirements:

• Minimum of three (3) years of experience processing and auditing Medicare and Medicaid professional, institutional, and dental health insurance claims
• Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, ICD-10 codes, and relevant federal and state regulations
• Experience working with CMS and Medicaid healthcare claims highly preferred
• Demonstrated skills within Microsoft Office Applications, including Excel

Benefits of Working at WelbeHealth: Apply your claims expertise in meaningful ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time
• Advancement opportunities - We’ve got a track record of hiring and promoting from within, meaning you can create your own path!
• And additional benefits

At WelbeHealth, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus lead the way no matter what.

The Claims Audit Specialist is accountable for ensuring the timely and accurate payment or denial of claims while meeting federal/state regulations, provider agreement terms, and company policies and procedures. This role requires a strong knowledge of health plan operations, including the proper processing of professional, institutional, and dental claims, coding, CMS/Medi-Cal regulations, and in-depth comprehension of provider contracts and agreements. The Claims Audit Specialist collaborates effectively with Plan Operations leadership to identify trends that require escalation and training needs, and suggest process improvements.

This role is different because the Claims Audit Specialist at WelbeHealth:

• Ensures accuracy and compliance by auditing complex Medicare and Medi-Cal claims, directly impacting financial integrity, regulatory adherence, and provider trust
• Plays a key role in identifying trends, mitigating risk, and driving process improvements across claims operations, helping strengthen overall system performance and reduce errors

We care about our team members. That’s why we offer:

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance - We mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days
• 401K savings + match
• Comprehensive compensation package including base pay and bonus
• And additional benefits!

On the day-to-day, you will:

• Review processed claims for pre and post payment accuracy while maintaining acceptable levels of aged claims inventory
• Ensure claim payment accuracy by verifying various aspects of the claim form, including but not limited to participant eligibility, system configuration, payment accuracy or denial appropriateness, provider records, remark codes, pre-authorization requirements, timely filing limitations, claim history, and W9 receipt
• Maintain detailed documentation of audit findings, including decision methodology, system configuration or manual processing errors, and monetary discrepancies
• Regularly provide feedback to the Oversight & Monitoring Manager on claims processing errors, as well as identify quality improvement opportunities and initiate configuration change requests when applicable
• Accurately process and release high dollar/stop loss claims exceeding $10k
• Participate in annual claims audits to cure any deficiencies in claims system, human error, or possible fraud, waste, and abuse in order to maintain contractual and regulatory compliance
• Act as a back up to the Claims team as needed

Job requirements include:

• Bachelor’s degree in relevant field; professional experience may be substituted
• Minimum of five (5) years of experience processing, researching, adjusting, and auditing Medicare and Medicaid professional, institutional, and dental health insurance claims
• Experience processing and auditing disputes, appeals and recoveries
• Proficient experience in Microsoft Excel
• Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, ICD-10 codes, and relevant federal and state regulations
• Experience working with CMS and Medi-Cal healthcare claims
• Strong organizational, analytical, communication, and time management skills

We are seeking a Claims Audit Specialist who is passionate about accuracy, compliance, and continuous improvement within healthcare operations. If you are driven to make a meaningful impact by ensuring claims integrity and supporting high-quality, compliant processes, we’d love to hear from you!