Claims Examiner I

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

📋 Description

• Process and adjudicate claims related to medical, dental, vision, and mental health services.

• Conduct research on claims with varying levels of complexity when necessary.

• Review and process insurance claims to ensure medical necessity and coverage compliance with policy guidelines using clinical edit logic.

• Achieve or surpass qualitative and quantitative production benchmarks.

• Facilitate investigations regarding claims.

• Negotiate settlements and interpret medical documentation.

• Address complaints filed with the Department of Insurance.

• Authorize payments for claimants and healthcare providers.

• Review and recover overpayments made on claims.

• Correct financial records for patients and service providers.

• Track complaints and their resolutions using designated systems.

• Resolve appeals related to claims.

• Research benefits as needed.

• Verify the correct loading of plans.

⛳️ Requirements

• A minimum of 2 years of relevant work experience.

• Experience as a claims examiner or adjudicator utilizing a computerized claims payment system within the healthcare sector.

• Possession of a high school diploma or GED.

• Familiarity with CPT and ICD-10 coding.

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

• Demonstrated judgment and decision-making capabilities.

• Ability to analyze information, learn quickly, and manage multiple tasks simultaneously.

• Strong interpersonal skills to maintain positive relationships with physicians, healthcare facilities, clients, and providers.

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

• Proficiency in Microsoft Windows, Word, Excel, and custom medical CPT coding software.

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

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

• Some college coursework in relevant fields is advantageous.

• Availability to work Monday to Friday from 8:00 am to 4:30 pm Central Time for four weeks of training.

🏝️ Benefits

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

• Short- and long-term disability programs.

• Flexible scheduling options following training.

• Work-from-home opportunities after training.

• 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.

• A robust wellness program.