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 across varying levels of complexity.

• Review insurance policies to ensure medical necessity and coverage in accordance with policy guidelines utilizing clinical edit logic.

• Achieve or surpass established qualitative and quantitative production standards.

• Facilitate investigations of claims and negotiate settlements.

• Interpret medical records accurately.

• Address complaints from the Department of Insurance.

• Authorize payments to both claimants and providers.

• Review and recover overpayments related to claims.

• Correct financial histories for patients and service providers.

• Monitor complaints and resolutions using designated tracking systems.

• Resolve appeals related to claims.

• Conduct research on benefits.

• Verify accurate plan loading.

• Attend training sessions from Monday to Friday, 8:00 a.m. to 4:30 p.m. Central Time for a duration of four weeks.

⛳️ 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.

• Proficiency in CPT and ICD-10 coding is necessary.

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

• Demonstrated judgment, decision-making capabilities, and analytical skills.

• Ability to learn swiftly and manage multiple tasks effectively.

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

• Strong written and verbal communication skills, including the ability to resolve conflicts.

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

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

• Completion of some college coursework in related fields is advantageous.

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

• Data entry skills and proficiency in 10-key by touch/sight are required.

🏝️ Benefits

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

• Short- and long-term disability programs available.

• Flexible scheduling options after training completion.

• Opportunities for remote work following training.

• Leave programs to accommodate personal circumstances.

• Retirement Savings Plan with employer contributions and matching options.

• Paid time off benefits.

• Volunteer time off available.

• 11 paid holidays each year.

• Additional voluntary benefits offered.

• A robust wellness program to support overall health.