Claims Examiner I

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

📋 Description

• Process claims related to medical, dental, vision, and mental health for designated accounts.

• Evaluate claims and carry out claims research as necessary.

• Assess insurance coverage and medical necessity in accordance with policy guidelines and clinical edit logic.

• Achieve or surpass both qualitative and quantitative production benchmarks.

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

• Review and reclaim overpayments on claims, while rectifying patient and provider financial histories.

• Monitor complaints and resolutions using specified systems.

• Address claims appeals.

• Conduct research on benefits.

• Confirm accurate plan loading.

⛳️ Requirements

• Minimum of 2 years of relevant work experience.

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

• High school diploma or GED required.

• Familiarity with CPT and ICD-9 coding.

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

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

• Capacity to learn swiftly and manage multiple tasks.

• Capability to maintain strong relationships with physicians, healthcare facilities, clients, and providers.

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

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

• Ability to review various surgical procedures and determine reasonable and customary fees.

• Available for training sessions from Monday to Friday, 8:00 AM–4:30 PM Central Time for a duration of 4 weeks.

🏝️ Benefits

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

• Short-term and long-term disability programs.

• Flexible work schedules available following training.

• Leave programs designed to accommodate personal circumstances.

• Retirement Savings Plan featuring employer contributions and matching.

• Paid time off.

• Volunteer time off.

• 11 recognized holidays.

• Additional optional benefits.

• Extensive wellness program.