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 as necessary, addressing a variety of complexities.

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

• Achieve or surpass both qualitative and quantitative production goals.

• Facilitate investigations into claims.

• Negotiate settlements effectively.

• Interpret medical records accurately.

• Address complaints from the Department of Insurance.

• Authorize payments to claimants and healthcare providers.

• Review and recover overpayments related to claims.

• Correct financial histories for patients and service providers.

• Track complaints and resolutions using specified systems.

• Resolve appeals regarding claims.

• Conduct research on benefits.

• Verify the correct loading of plans.

⛳️ 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 is required.

• Familiarity with CPT and ICD-9 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 rapidly, and manage multiple tasks simultaneously.

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

• Clear written and verbal communication skills, including the ability to manage conflicts.

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

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

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

• Some college coursework in related fields is advantageous.

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

🏝️ Benefits

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

• Short- and long-term disability programs.

• Flexible work schedules available after the training period.

• Work-at-home options.

• Leave programs designed to accommodate personal circumstances.

• Retirement Savings Plan with employer contributions and matching.

• Paid time off (PTO).

• Volunteer time off (VTO).

• 11 paid holidays.

• Additional voluntary benefits.

• An extensive wellness program.