Claims Examiner I – Part Time

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 with varying levels of complexity as needed.

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

• Achieve or surpass both qualitative and quantitative production standards.

• Facilitate investigations into claims and negotiate settlements effectively.

• Interpret medical records and address complaints from the Department of Insurance.

• Authorize payments for claimants and healthcare providers.

• Review claims for overpayments, recover funds, and correct financial histories.

• Monitor complaints and their resolutions using designated systems.

• Resolve appeals related to claims.

• Research benefits and verify the accurate loading of plans.

⛳️ Requirements

• A minimum of 2 years of relevant work experience.

• Experience as a claims examiner or adjudicator on a computerized claims payment system within the healthcare sector.

• High school diploma or GED is required.

• Familiarity with CPT and ICD-10 coding is essential.

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

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

• Ability to learn swiftly and manage multiple tasks simultaneously.

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

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

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

• Experience reviewing various surgical procedures and establishing reasonable and customary fees.

• Competence in data entry and touch/sight 10-key skills.

🏝️ Benefits

• Equal Employment Opportunity employer dedicated to fostering an inclusive work environment where everyone can thrive and perform at their best.

• Training schedule: Monday to Friday, 8:00 AM to 4:30 PM Central Time.

• Four weeks of comprehensive training.