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 necessary, accommodating various levels of claim complexity.

• Review and process insurance to confirm medical necessity and coverage in accordance with policy guidelines using clinical edit logic.

• Achieve or surpass established qualitative and quantitative production standards.

• Facilitate investigations into claims.

• Negotiate settlements effectively.

• Interpret medical records accurately.

• Address complaints received from the Department of Insurance.

• Authorize payments to both claimants and providers.

• Review and recover any overpayments on claims.

• Correct financial histories pertaining to patients and service providers.

• Monitor complaints and their resolutions utilizing designated systems.

• Resolve appeals related to claims.

• Research various benefits to ensure accurate processing.

• Verify the accurate loading of plans.

⛳️ Requirements

• Minimum of 2 years of relevant work experience.

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

• High school diploma or GED is 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 and decision-making abilities.

• Capacity to analyze information, learn swiftly, and manage multiple tasks simultaneously.

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

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

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

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

• Some college coursework in related disciplines is advantageous.

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

• Proficient in data entry and 10-key by touch or sight.

🏝️ Benefits

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

• Short- and long-term disability programs available.

• Flexible scheduling options after the training period.

• Opportunities for remote work following training.

• Leave programs tailored to accommodate personal situations.

• Retirement Savings Plan featuring employer contributions and matching.

• Paid time off for personal use.

• Volunteer time off to support community involvement.

• 11 recognized holidays throughout the year.

• Additional voluntary benefits offered.

• A comprehensive wellness program to support employee health.