Claims Examiner

Primary Responsibilities

• Adjudicate new claims and process adjustments, including denials upon receipt of additional information
• Review and resolve appeals and subrogation/third-party liability cases
• Manage individual inventory to ensure timely turnaround and production goals are met
• Ensure claims are processed in accordance with stop loss contract terms
• Respond to internal and external inquiries via email and other channels within established timeframes
• Follow up on missing or incomplete information to ensure claims can be accurately processed
• Maintain minimum production, financial, and procedural accuracy standards on a monthly basis

Qualifications

• Experience with Third Party Administrator (TPA) or self-funded claims administration preferred
• At least 2+ years of experience in insurance claims processing required
• Experience reviewing and finalizing claim payments for accuracy in accordance with plan policies
• Demonstrated understanding of both claim review processes and underlying benefit plan design
• Experience with HealthPac, El Dorado, Javelina, or VBA systems preferred
• Working knowledge of CPT and ICD-10 coding
• Basic understanding of medical terminology
• Strong communication and customer service skills
• Proficiency in Microsoft Office and general computer applications
• Able to maintain confidentiality and comply with all company policies and procedures
• Able to work independently with minimal supervision
• Able to prioritize, multitask, and work overtime as needed
• Associate Degree Preferred