Health Claims Examiner

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

📋 Description

• Accurately and promptly process claims related to medical, dental, vision, and prescription drugs.

• Verify all necessary documentation for claims.

• Work collaboratively with providers, plan participants, other insurers, and relevant stakeholders to gather claim details.

• Analyze information pertaining to participants, providers, diagnoses, services, procedures, and charges.

• Ensure that claims are processed accurately and that payments are made in accordance with the plan.

• Prepare communications regarding pre-determinations and basic inquiries related to benefits.

• Respond to calls from participants, group contacts, and customer service representatives concerning benefits and claims.

• Troubleshoot and resolve complex claims issues with guidance from claims leadership.

• Assign severely ill patients to large case management and support case managers.

• Provide backup assistance to fellow examiners.

• Aid in claim appeals and disputes by supplying necessary documentation.

• Conduct research, perform calculations, and request refunds as needed.

• Maintain consistent and punctual attendance while contributing to daily operational workflow.

• Complete renewal reports and process eligible claims prior to the expiration of stop-loss contract renewal periods.

• Assist with subrogation claims, group meetings, audits, and adjustments to plan benefits.

⛳️ Requirements

• Must have a high school diploma or GED.

• Basic computer skills are mandatory.

• Customer service experience is essential.

• Strong oral and written communication abilities are required.

• Proficiency in PC skills, including Windows and Word applications.

• Capability to learn and adapt to changes in claims processing software.

• Typing speed of at least 45 words per minute net is necessary.

• Excellent listening abilities are important.

• Fundamental mathematical skills are required.

• Strong interpersonal skills to effectively collaborate with others.

• Ability to organize and recall detailed information efficiently.

• Capacity to interpret benefit plans, insurance documents, and regulations, applying them to specific scenarios.

• Must meet productivity standards of 99% financial accuracy and 95% procedural accuracy.

• Comprehensive understanding of claims processing procedures and requirements is necessary.

• Ability to maintain privacy and confidentiality is crucial.

• Flexibility to work under pressure and meet deadlines is required.

• Problem-solving skills and sound judgment are essential.

• Proficiency in operating common office equipment is needed.

• Familiarity with general office procedures is expected.

• If working from home, reliable internet service through cable broadband or fiber optic with a minimum of 10 Mbps download and 5 Mbps upload is required.

🏝️ Benefits

• Remote work opportunities may be available, either occasionally or permanently.

• Home working requires cable broadband or fiber optic internet service with at least 10 Mbps download and 5 Mbps upload.

• Reasonable accommodations are offered for the online application process.