Claims Examiner I

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

📋 Description

• Manage the processing of medical, dental, vision, and mental health claims.

• Execute claims processing and adjudication tasks.

• Conduct research on claims as necessary.

• Evaluate and process insurance claims to confirm medical necessity and adherence to policy guidelines and clinical edit logic.

• Achieve and/or surpass established qualitative and quantitative production benchmarks.

• Facilitate investigations into claims.

• Negotiate settlements effectively.

• Analyze medical records for clarity and accuracy.

• Address complaints from the Department of Insurance.

• Authorize payments to both claimants and healthcare providers.

• Review and recover any overpayments related to claims.

• Rectify financial records for patients and service providers.

• Monitor complaints and their resolutions through various systems.

• Resolve appeals related to claims.

• Research available benefits.

• Verify the accurate loading of plans.

⛳️ Requirements

• Minimum of 2 years of relevant work experience.

• Experience as a claims examiner or in adjudication on a computerized claims payment system within the healthcare field.

• High school diploma or GED is essential.

• Proficiency in CPT and ICD-9 coding is required.

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

• Demonstrated judgment and decision-making capabilities.

• Strong analytical skills, quick learning ability, and multitasking proficiency.

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

• Excellent written and verbal communication skills, including conflict resolution abilities.

• Proficient in Microsoft Windows, Word, Excel, and specialized programs for medical CPT coding.

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

• Some college coursework in related disciplines is advantageous.

• Additional experience in processing various types of medical claims is beneficial.

• Competence in data entry and 10-key by touch/sight.

🏝️ Benefits

• Comprehensive medical, dental, vision, life, and global travel health insurance.

• Life insurance coverage.

• Short- and long-term disability programs.

• Flexible scheduling options available after training.

• Work-at-home options.

• Leave programs to accommodate personal circumstances.

• Retirement Savings Plan with employer contributions and matching.

• Paid time off.

• Volunteer time off.

• 11 paid holidays.

• Additional voluntary benefits offered.

• A comprehensive wellness program.