Claims Examiner I

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

📋 Description

• Process and adjudicate healthcare claims for medical, dental, vision, and mental health accounts.

• Conduct claims research as needed across various complexities of claims.

• Review insurance to ensure medical necessity and policy coverage using clinical edit logic.

• Achieve or surpass qualitative and quantitative production standards.

• Facilitate claims investigations, negotiate settlements, interpret medical records, address Department of Insurance complaints, and authorize payments.

• Review and recover overpayments on claims and rectify patient and provider financial histories.

• Track complaints and their resolutions using designated systems.

• Resolve claims appeals effectively.

• Research benefits thoroughly.

• Verify accurate plan loading.

⛳️ Requirements

• A minimum of 2 years of relevant work experience.

• Experience as a claims examiner/adjudicator on a computerized claims payment system within the healthcare sector.

• High school diploma or GED is required.

• Familiarity with CPT and ICD-10 coding is essential.

• Understanding of COBRA, HIPAA, pre-existing conditions, and coordination of benefits is necessary.

• Demonstrated judgment and decision-making abilities.

• Capacity to analyze, learn swiftly, and handle multiple tasks simultaneously.

• Ability to maintain positive relationships with physicians, healthcare facilities, clients, and providers.

• Strong written and verbal communication skills, with the ability to manage conflicts effectively.

• Proficiency in using Microsoft Windows, Word, Excel, and specialized medical CPT coding programs.

• Experience in reviewing multiple surgical procedures and determining reasonable and customary fees.

• Data entry skills and 10-key proficiency by touch/sight are preferred.

🏝️ Benefits

• Medical, dental, vision, life, and global travel health insurance.

• Short- and long-term disability programs.

• Flexible schedules available after training.

• Work-from-home options provided following training.

• Leave programs designed to support personal circumstances.

• Retirement Savings Plan with employer contributions and matching.

• Paid time off.

• Volunteer time off.

• 11 paid holidays.

• Additional voluntary benefits available.

• Comprehensive wellness program.