Claims Examiner I

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

📋 Description

• Manage medical, dental, vision, and mental health claims for designated accounts.

• Execute claims processing and adjudication across a range of claim complexities.

• Investigate claims as necessary.

• Assess and process insurance to confirm medical necessity and policy coverage utilizing clinical edit logic.

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

• Oversee claims investigations and negotiate settlements.

• Analyze medical records.

• Address complaints from the Department of Insurance.

• Approve payments to claimants and providers.

• Examine and recover overpayments on claims.

• Amend patient and provider financial records to ensure accuracy.

• Monitor complaints and resolutions using specified systems.

• Resolve claims appeals effectively.

• Investigate benefits.

• Confirm correct plan loading.

⛳️ Requirements

• Minimum of 2 years of relevant work experience.

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

• High school diploma or GED required.

• Familiarity with CPT and ICD-9 coding is essential.

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

• Demonstrated judgment, decision-making, and analytical capabilities.

• Ability to quickly learn and handle multiple tasks simultaneously.

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

• Clear written and verbal communication skills, including conflict resolution capabilities.

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

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

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

• Some college coursework in related fields is advantageous.

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

🏝️ Benefits

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

• Short- and long-term disability programs.

• Flexible scheduling options after training.

• Work-from-home opportunities following training.

• Leave programs to accommodate personal situations.

• Retirement Savings Plan with employer contributions and matching.

• Paid time off.

• Volunteer time off.

• 11 paid holidays.

• Additional voluntary benefits available.

• Comprehensive wellness program.