Claims Examiner

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate new claims and process modifications, including denials upon receipt of supplementary information.

• Examine and address appeals along with subrogation and third-party liability cases.

• Oversee individual inventory to guarantee timely turnaround and achievement of production targets.

• Ensure claims are managed in accordance with stop loss contract stipulations.

• Address internal and external inquiries through email and other communication channels within specified timeframes.

• Follow up on missing or incomplete information to ensure claims can be processed accurately.

• Maintain minimum standards for production, financial accuracy, and procedural compliance on a monthly basis.

⛳️ Requirements

• Preferred experience with Third Party Administrator (TPA) or self-funded claims administration.

• A minimum of 2+ years of experience in insurance claims processing is required.

• Experience in reviewing and finalizing claim payments for accuracy in line with plan policies.

• Ability to interpret and apply plan documents to ensure precise claims adjudication.

• Demonstrated understanding of both the claim review processes and the underlying benefit plan design.

• Preferred experience with systems such as HealthPac, El Dorado, Javelina, or VBA.

• Familiarity with CPT and ICD-10 coding.

• Basic knowledge of medical terminology.

• Strong communication and customer service capabilities.

• Proficient in Microsoft Office and general computer applications.

• Ability to maintain confidentiality and adhere to all company policies and procedures.

• Capacity to work independently with minimal supervision.

• Ability to prioritize tasks, multitask, and work overtime as necessary.

• Associate Degree is preferred.

🏝️ Benefits

• Comprehensive medical, dental, vision, and life insurance coverage.

• 401(k) retirement plan with employer matching.

• Health Savings Account (HSA) & Flexible Spending Accounts (FSAs).

• Paid time off (PTO) and disability leave.

• Employee Assistance Program (EAP).