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 as needed, accommodating varying levels of complexity.

• Review and process insurance claims to ensure medical necessity and adherence to policy guidelines and clinical edit logic.

• Achieve or surpass both qualitative and quantitative production benchmarks.

• Facilitate investigations into claims.

• Negotiate settlement agreements.

• Interpret medical documentation accurately.

• Address complaints from the Department of Insurance.

• Authorize payments to both claimants and service providers.

• Review and recover overpayments related to claims.

• Amend financial histories for patients and service providers.

• Track complaints and their resolutions using established systems.

• Resolve appeals related to claims.

• Conduct research on benefits.

• Verify the correct 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 within the healthcare sector.

• High school diploma or equivalent (GED).

• Required knowledge of CPT and ICD-9 coding.

• Familiarity with COBRA, HIPAA, pre-existing conditions, and coordination of benefits is essential.

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

• Ability to quickly learn and handle multiple tasks simultaneously.

• Skill in maintaining positive relationships with physicians, healthcare facilities, clients, and providers.

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

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

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

• Completion of some college courses in related fields is advantageous.

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

• Competence in data entry and touch/sight 10-key skills.

🏝️ Benefits

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

• Short-term and long-term disability programs.

• Flexible work schedules following training.

• Opportunities for remote work after training.

• Leave programs designed to accommodate personal situations.

• Retirement Savings Plan that includes employer contributions and matching.

• Paid time off.

• Volunteer time off.

• 11 paid holidays.

• Additional voluntary benefits available.

• An extensive wellness program.