Claims Examiner

About the role

A local client is looking to hire an experienced Claims Processor / Customer Service Representative to join their growing team. This is an excellent opportunity for someone with medical and dental claims processing experience who enjoys working in a detail-oriented environment and providing exceptional service to members and providers. The ideal candidate will have a strong understanding of group health benefits, claims adjudication, medical terminology, and healthcare regulations. This role requires strong analytical skills, accuracy, and the ability to maintain production standards while delivering high-quality work.

Responsibilities

• Process medical and dental claims accurately and efficiently according to plan provisions and benefit guidelines.
• Interpret plan benefits, eligibility requirements, exclusions, limitations, and coverage provisions.
• Review, analyze, and adjudicate claims while ensuring compliance with company policies and procedures.
• Maintain knowledge of PPO guidelines, coordination of benefits (COB), Medicare, and supplemental benefit plans.
• Utilize company and carrier systems to process claims, enter data, and maintain accurate records.
• Respond to member and provider inquiries regarding eligibility, benefits, and claims status.
• Provide clear and accurate information directly from plan documents without offering benefit advice.
• Document customer interactions, eligibility requests, and benefit inquiries thoroughly and accurately.
• Communicate professionally with participants, providers, and internal teams via phone, email, fax, correspondence, and in person.
• Assist management, auditors, and team members with special projects and additional responsibilities as needed.
• Attend training sessions, team meetings, and ongoing professional development opportunities.

Preferred Experience

• Experience working with Anthem Blue Cross systems or similar carrier platforms.
• Previous customer service experience in a healthcare or benefits administration setting.
• Experience processing both medical and dental claims in a high-volume environment.

Qualifications

• Detail-oriented and highly organized professional.
• Ability to work efficiently while maintaining accuracy and quality.
• Strong time management and multitasking skills.
• Excellent customer service mindset.
• Ability to understand and follow complex written and verbal instructions.
• Flexible, dependable, and willing to support team initiatives.
• Collaborative team player who works well with others.