Claims Examiner I

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

📋 Description

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

• Conduct research on claims as needed, addressing various complexities.

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

• Achieve or surpass both qualitative and quantitative production standards.

• Facilitate investigations into claims, negotiate settlements, interpret medical records, respond to complaints from the Department of Insurance, and authorize payments.

• Review and recover any claim overpayments.

• Correct financial histories for patients and providers to ensure accurate records.

• Track complaints and their resolutions using specified systems.

• Resolve appeals related to claims.

• Research benefits.

• Verify the accurate loading of plans.

⛳️ Requirements

• A minimum of 2 years of relevant work experience.

• Experience as a claims examiner or adjudicator using a computerized claims payment system in 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 multitask effectively.

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

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

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

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

🏝️ Benefits

• Full-time position.

• Training schedule: Monday to Friday, 8:00 AM to 4:30 PM Central Time.

• Four-week training program.