Health Claims Examiner

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

📋 Description

• Accurately and promptly process medical, dental, vision, and prescription drug claims.

• Verify the necessary documentation for claims.

• Collaborate with providers, plan participants, other payers, and relevant stakeholders to gather claim information.

• Analyze participant and provider data, including diagnosis codes, service dates, services rendered, procedure codes, and associated charges.

• Ensure that claims are processed correctly, and payments are calculated in accordance with the plan.

• Draft correspondence related to pre-determinations and basic questions about benefits.

• Respond to inquiries from participants, group contacts, and customer service regarding benefits and claims.

• Resolve complex claims issues with assistance from claims leadership.

• Assign critically ill patients to large case management and support case managers in benefit negotiations.

• Provide backup assistance to fellow examiners.

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

• Conduct research, perform calculations, and initiate requests for refunds.

• Prepare renewal reports and process eligible claims prior to the expiration of stoploss contract renewal periods.

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

• Maintain consistent and punctual attendance to support daily operations.

⛳️ Requirements

• High school diploma or GED is mandatory.

• Fundamental computer skills and customer service experience are essential.

• Exceptional oral and written communication abilities are required.

• Proficient in PC usage, including Windows and Word.

• Capability to learn and utilize claims processing software, adapting to software updates.

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

• Strong listening skills are necessary.

• Basic mathematical proficiency is required.

• Ability to organize and recall detailed information effectively.

• Competence in reading, analyzing, and interpreting benefit plans, insurance documents, and regulations while applying them to specific scenarios.

• Capacity to meet productivity benchmarks with 99% financial accuracy and 95% procedural accuracy.

• Comprehensive understanding of claims processing protocols and requirements.

• Ability to adhere to privacy and confidentiality standards.

• Flexibility to work under pressure and adhere to deadlines is essential.

• Skills in analyzing and resolving issues, exercising sound judgment, and making professional decisions.

• Proficient in operating standard office equipment.

• Familiarity with general office procedures is beneficial.

🏝️ Benefits

• Option for remote work arrangement.

• Requirement for work-from-home internet connection: cable broadband or fiber optic service with a minimum of 10Mbps download and 5Mbps upload.

• Tobacco-free workplace policy along with smoking cessation program opportunities where applicable.