Claims Examiner

Community First Health Plans is a locally owned and managed, non-profit health plan serving the San Antonio area and surrounding counties. The organization is committed to providing high-quality health care coverage for individuals and families, with a focus on access to essential services and supports. Its mission centers on improving health outcomes for Members and enhancing the overall health of the community. As a community-focused health plan, a portion of all proceeds is reinvested directly into local initiatives. Team members join an organization that values service, equity, and long-term community impact.

About the role

The Claims Examiner is a full-time, on-site role based in San Antonio, TX. This role is responsible for reviewing, analyzing, and adjudicating health care claims in accordance with policies, procedures, contracts, and regulatory requirements. Day-to-day tasks include validating claim information, applying appropriate coding and billing guidelines, and resolving discrepancies or complex claim issues. The Claims Examiner collaborates with internal departments and other stakeholders to clarify documentation, support accurate claim decisions, and ensure timely processing.

Responsibilities

• Review, analyze, and adjudicate health care claims in accordance with policies, procedures, contracts, and regulatory requirements.
• Validate claim information and apply appropriate coding and billing guidelines.
• Resolve discrepancies or complex claim issues.
• Collaborate with internal departments and stakeholders to clarify documentation and support accurate claim decisions.
• Maintain detailed records and meet performance and quality standards.
• Contribute to continuous improvement of claims processes.
• Perform claims resolution activities, including reviewing denied or disputed claims, identifying root causes, and implementing corrections or adjustments.
• Conduct claim investigations, verifying documentation, detecting inconsistencies, and assessing potential fraud, waste, or abuse.

Qualifications

• Demonstrated skills in Claims Handling and Claims Management, with experience processing health care insurance claims from receipt through final disposition.
• Ability to perform Claims Resolution activities, including reviewing denied or disputed claims, identifying root causes, and implementing appropriate corrections or adjustments.
• Knowledge of Insurance principles and health plan benefits, including policy interpretation, coverage determination, and regulatory compliance.
• Proficiency in Claim Investigation, including verifying documentation, detecting inconsistencies, and assessing potential fraud, waste, or abuse.
• Strong attention to detail, analytical thinking, and problem-solving abilities in a fast-paced, deadline-driven environment.
• Effective written and verbal communication skills for interacting with providers, colleagues, and members in a professional manner.
• Familiarity with medical terminology, coding (ICD, CPT, HCPCS), and standard claims processing systems is preferred.
• High school diploma or equivalent required; additional education or certifications in health insurance, billing, or claims administration are a plus.
• Ability to work on-site in San Antonio, TX, and collaborate as part of a diverse, mission-driven team.