Claims Examiner I

This is a fully remote position, open to applicants in Texas.

📋 Description

• Manage claims related to medical, dental, vision, and mental health services.

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

• Conduct research on claims when necessary.

• Review and process insurance to confirm medical necessity and coverage in line with policy guidelines.

• Achieve or surpass qualitative and quantitative production benchmarks.

• Facilitate investigations into claims.

• Negotiate settlements effectively.

• Interpret medical records accurately.

• Address complaints from the Department of Insurance.

• Authorize payments to both claimants and providers.

• Review and recover any overpayments on claims.

• Correct financial histories for patients and service providers.

• Track complaints and their resolutions in relevant systems.

• Resolve appeals related to claims.

• Research benefits thoroughly.

• Confirm the accurate loading of plans.

⛳️ Requirements

• A 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 is required.

• Proficient knowledge of CPT and ICD-10 coding is mandatory.

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

• Demonstrated judgment and decision-making abilities.

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

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

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

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

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

• Skilled in data entry and proficient in 10-key by touch/sight.

🏝️ Benefits

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

• Short-term and long-term disability programs.

• Flexible scheduling options following training.

• Potential future work-from-home opportunities.

• Leave programs designed to accommodate personal circumstances.

• Retirement Savings Plan with employer contributions and matching.

• Paid time off.

• Volunteer time off.

• 11 observed holidays.

• Additional voluntary benefits available.

• Extensive wellness program.