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.

• Carry out claims processing and adjudication across various levels of claim complexity.

• Investigate claims as necessary.

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

• Achieve or surpass qualitative and quantitative production standards.

• Manage claims investigations.

• Negotiate settlements effectively.

• Interpret medical records accurately.

• 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 service providers.

• Track complaints and their resolutions within relevant systems.

• Resolve appeals related to claims.

• Research benefits thoroughly.

• Verify proper loading of plans.

⛳️ Requirements

• Minimum of 2 years of relevant work experience.

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

• High school diploma or GED is required.

• Strong knowledge of CPT and ICD-10 coding is essential.

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

• Demonstrated judgment and decision-making capabilities.

• Ability to analyze effectively.

• Quick learning and multitasking skills are necessary.

• Ability to maintain 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.

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

• Data entry and 10-key proficiency (by touch/sight) are preferred.

🏝️ Benefits

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

• Income protection benefits including life insurance and short- and long-term disability programs.

• Flexible work schedules available after training.

• Work-from-home options offered post-training.

• Leave programs designed to accommodate personal situations.

• Retirement Savings Plan with employer contributions and matching.

• Paid time off.

• Volunteer time off.

• 11 paid holidays.

• Additional voluntary benefits available.

• An extensive wellness program.