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 across various complexities.

• Conduct research on claims as necessary.

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

• Achieve or surpass qualitative and quantitative production standards.

• Lead claims investigations and negotiate settlements.

• Analyze medical records and address complaints from the Department of Insurance.

• Authorize payments to both claimants and providers.

• Review and recover overpayments on claims.

• Correct financial histories for patients and providers to ensure record accuracy.

• Monitor complaints and their resolutions using specified systems.

• Address claims appeals effectively.

• Research benefits and confirm correct plan loading.

⛳️ Requirements

• Minimum of 2 years of relevant work experience.

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

• High school diploma or GED required.

• Proficiency in CPT and ICD-10 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 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 the capability to manage conflicts.

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

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

🏝️ Benefits

• Full-time employment opportunity.

• Training schedule: Monday to Friday, 8:00 AM to 4:30 PM Central Time.

• Comprehensive training lasting four weeks.

• Commitment to Equal Employment Opportunity and consideration for all qualified candidates.