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 services.

• Execute claims processing and adjudication for a range of complexities.

• Conduct research on claims as necessary.

• Review and handle insurance to confirm medical necessity and policy coverage utilizing clinical edit logic.

• Achieve or surpass both qualitative and quantitative production benchmarks.

• Manage claims investigations and negotiate settlements.

• Interpret medical records accurately.

• Address complaints directed to the Department of Insurance.

• Authorize payments to both claimants and providers.

• Review and recuperate overpayments on claims.

• Correct financial histories for patients and service providers.

• Monitor complaints and their resolutions using appropriate systems.

• Resolve appeals related to claims.

• Investigate benefits thoroughly.

• Ensure accurate plan loading.

⛳️ Requirements

• Minimum of 2 years of relevant work experience.

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

• High school diploma or GED required.

• Familiarity with CPT and ICD-10 coding.

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

• Demonstrated judgment and decision-making abilities.

• Capability to analyze, learn rapidly, and manage multiple tasks simultaneously.

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

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

• Proficiency in Microsoft Windows and Office Suite, including Word, Excel, and specialized programs for medical CPT coding.

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

🏝️ Benefits

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

• Life insurance coverage.

• Short- and long-term disability programs.

• Flexible work schedules following training completion.

• Potential for future remote work opportunities.

• Leave programs designed to support personal circumstances.

• Retirement Savings Plan with employer contributions and matching.

• Paid time off for vacations and personal use.

• Volunteer time off to support community service efforts.

• 11 paid holidays throughout the year.

• Additional voluntary benefits available.

• A comprehensive wellness program to promote health and well-being.