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 that vary in complexity as needed.

• Review and process insurance claims to validate medical necessity and coverage according to policy guidelines utilizing clinical edit logic.

• Achieve and surpass qualitative and quantitative production benchmarks.

• Facilitate investigations into claims.

• Negotiate settlement agreements.

• Interpret medical documentation.

• Address complaints from the Department of Insurance.

• Authorize payments to both claimants and providers.

• Review and recover any overpayments made on claims.

• Correct financial histories for patients and service providers.

• Monitor complaints and their resolutions through various systems.

• Resolve appeals related to claims.

• Conduct research on 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.

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

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

• Demonstrated judgment and decision-making capabilities.

• Ability to analyze information, learn swiftly, and manage multiple tasks simultaneously.

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

• Strong written and verbal communication skills, including conflict resolution abilities.

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

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

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

🏝️ Benefits

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

• Life insurance coverage.

• Short- and long-term disability programs.

• Flexible work schedules following training completion.

• Opportunities for future remote work.

• Leave programs designed to accommodate personal circumstances.

• Retirement Savings Plan with employer contribution and matching.

• Paid time off.

• Volunteer time off.

• 11 paid holidays.

• Additional voluntary benefits available.

• A comprehensive wellness program.