Jobs and Careers

Claims Examiner I

United Statesfull_timeVerifiedPosted 31 Mar 2026

💰 $52,756/yr($40,580/yr – $52,756/yr)

About the role

If you’re looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we’re looking for you.       

At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full-suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.               

As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn’t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee’s life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.                

With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees’ job satisfaction and success.             

Compensation: $40,580.28 - $52,756.02 with a rich benefits package that includes profit-sharing.

JOB DESCRIPTION SUMMARY

The Claims Examiner I reports to the Supervisor of Claims. Claims Examiner I is responsible for reviewing and processing medical, dental, vision, and electronic claims per state, federal, and health plan regulatory requirements and department guidelines, as well as meeting established quality and production performance benchmarks, including research and review of applicable documentation. The Claims Examiner I will thoroughly review, analyze, and research health care claims in order to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position will assist in resolving issues from providers, customer service, member services, health plan, and other internal customers.

QUALIFICATIONS

• High school education or equivalent: minimum three (3) to five (5) years of experience as a Health Claims Examiner or comparable industry experience preferred.

• A minimum of one (1) year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims, highly desired.

• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination.

• Basic knowledge of medical terminology. Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.

• Good verbal and written communication skills.

• Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.

• Ability to work under pressure and adapt to changing environment

• Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims

processing/adjudication guidelines.

• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.

• Home router with wired Ethernet (wireless connections and hotspots are not permitted).

• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)

• A functioning smoke detector, fire extinguisher, and first aid kit on site.

DUTIES AND RESPONSIBILITIES

Claims Processing & Quality Assurance

• Adjudicate all claims types including Dental, Vision and Medical claims for inpatient and outpatient facilities, Blue Card, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.

• Analyze patient and medical records to identify instances where investi