Health Claims Examiner I

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

📋 Description

• Assess and analyze health insurance claims to establish their eligibility for payment.

• Examine claim documentation, which includes claim forms, medical records, beneficiary records, and supporting materials.

• Confirm policy status, coverage amounts, policyholder details, and history of premium payments.

• Acquire and review any additional documentation necessary to finalize claim evaluations.

• Communicate with policyholders, agents, and other relevant parties regarding claim requirements and their status.

• Reach out to medical facilities, providers, legal entities, policyholders, and agents to gather required documents.

• Process routine health insurance claims within established authority limits and service-level expectations.

• Identify and escalate complex, contestable, suspicious, or high-risk claims to management.

• Record claim activities, decisions, and communications in company systems.

• Ensure adherence to federal and state regulations, company policies, privacy standards, and internal controls.

• Calculate benefits, interest, and applicable deductions related to claims.

• Collaborate with Legal, Compliance, Underwriting, Customer Care, Accounting, and Information Technology departments.

• Address inquiries from customers and agents in a professional, empathetic, and timely manner.

• Uphold departmental standards for productivity, quality, and turnaround times.

• Engage in training, process improvement initiatives, and ongoing education.

• Support special projects and perform other assigned duties.

⛳️ Requirements

• Bachelor's degree, or 2–5 years of relevant experience and/or training, or a suitable combination of education and experience.

• At least 1 year of experience in a claims support position.

• Previous experience in health insurance, claims administration, customer service, banking, legal support, or healthcare operations.

• Progress toward or completion of insurance industry coursework or designations such as FLMI, ALHC, or ACS.

• Basic understanding of health insurance products, policy provisions, claims payment processes, and state insurance regulations.

• Familiarity with HIPAA, privacy regulations, data security standards, and health-claims compliance requirements.

• Proficient in claim management systems, workflow applications, document imaging platforms, and Microsoft Office.

• Strong analytical, problem-solving, and attention-to-detail abilities.

• Effective verbal and written communication skills, alongside strong customer service capabilities, including professionalism and empathy.

• Excellent organizational and time-management skills; ability to handle multiple claims while meeting productivity and service-level expectations.

• Capacity to interpret policy provisions, work independently, exercise sound judgment, and adapt to evolving priorities and regulatory requirements.

• Strong teamwork and collaboration capabilities.

• Bilingual skills are an advantage.

• Consistent and reliable attendance during assigned shifts.

• Availability to work full-time and/or part-time as per position specifications.

🏝️ Benefits

• Competitive compensation tailored to reflect your expertise and contributions.

• Comprehensive health, dental, and vision insurance options.

• Generous life insurance benefits.

• Company-matched 401k plan.

• Pension plan.

• Paid holidays and time off.

• Parental leave.

• Subsidized all-in-one subscriptions for fitness, mindfulness, nutrition, and sleep.

• Company-funded counseling services for mental health, stress management, and work-life balance.

• Eligibility for continued education reimbursement.

• Company-sponsored FLMI and ICA courses.

• Discounted tickets to Texas Rangers games.