Claims Examiner

About the Company

Our client is an established organization within the insurance and healthcare services industry focused on delivering accurate, timely, and high-quality claims support. The team values collaboration, attention to detail, continuous improvement, and providing responsive service to clients and business partners.

About the Role

The Claims Examiner will be responsible for reviewing, evaluating, and processing healthcare-related insurance claims. This position requires a strong understanding of claims procedures, benefit information, documentation requirements, and applicable regulations. The ideal candidate is detail-oriented, analytical, organized, and able to communicate effectively with both internal and external stakeholders.

Responsibilities

• Review submitted claims to verify eligibility, required documentation, accuracy, and applicable coverage.
• Evaluate claims using plan provisions, established procedures, and applicable benefit guidelines.
• Determine appropriate claim outcomes, including approvals, adjustments, payment calculations, or denial determinations.
• Prepare or coordinate claim-related correspondence when additional information or a denial explanation is required.
• Follow applicable federal and state regulations, privacy requirements, and internal claims procedures.
• Maintain complete and accurate records of claims, payments, adjustments, denials, and supporting documentation.
• Respond to questions from healthcare providers, clients, and internal teams regarding claim status and processing decisions.
• Identify potential payment discrepancies, including overpayments and underpayments, and escalate issues appropriately.
• Communicate with external partners and other stakeholders to obtain information necessary to complete claim reviews.
• Confirm member eligibility, benefit levels, authorizations, and coverage details as needed.
• Recognize missing or inconsistent documentation and work with the appropriate parties to resolve outstanding issues.
• Protect confidential information and follow HIPAA and other applicable privacy standards.
• Utilize claims systems, computer applications, and emerging technology tools to improve accuracy, efficiency, and service.
• Contribute to departmental projects, process improvements, and other duties as assigned.

Qualifications

• High school diploma or equivalent required.
• At least 1 year of experience in healthcare claims processing, reimbursement, or a related field.
• Ability to interpret written policies, benefit information, procedural guidelines, and government regulations.
• Proficiency with standard computer applications, including email, spreadsheets, word processing, and database systems.
• Strong attention to detail and the ability to analyze information and identify discrepancies.
• Effective problem-solving and decision-making skills.
• Strong written and verbal communication abilities.
• Ability to manage multiple priorities and adjust to changing workloads.
• Ability to work effectively with internal teams, providers, clients, and other business partners.

Additional Details

• This position requires a high level of accuracy and discretion when handling sensitive claims and member information.
• Candidates should be comfortable working independently while also collaborating with a broader team.
• The responsibilities listed above are representative of the position and may be modified based on business needs.

Benefits

• Medical, dental, vision, and 401(k).
• Competitive compensation.
• Paid time off and company holidays.
• Employee assistance and wellness resources.
• Professional development and career growth opportunities.
• Collaborative and supportive work environment.

Pay

$28/hr

Schedule

Mon-Fri, 8am-5pm