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, addressing various levels of complexity.

• Review and assess insurance claims to ensure medical necessity and compliance with policy guidelines.

• Achieve or surpass established qualitative and quantitative production benchmarks.

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

• Review and recover any overpayments related to claims.

• Correct financial records for both patients and service providers.

• Track complaints and their resolutions using designated systems.

• Resolve appeals related to claims.

• Research available benefits.

• Verify the accurate loading of plans.

⛳️ Requirements

• 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 GED is 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.

• Capacity to analyze information quickly 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 Microsoft Windows, Word, Excel, and specialized medical CPT coding software.

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

• Some college coursework in related disciplines is advantageous.

• Additional experience in processing various types of medical claims is beneficial.

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

🏝️ Benefits

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

• Short-term and long-term disability programs.

• Flexible work schedules following the training period.

• Opportunities for remote work after training.

• Leave programs to accommodate personal circumstances.

• Retirement Savings Plan with employer contributions and matching options.

• Paid time off.

• Volunteer time off.

• 11 paid holidays.

• Additional voluntary benefits available.

• A thorough wellness program.