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
• 1-2 years of experience in insurance claims processing required
• Experience reviewing and finalizing claim payments for accuracy in accordance with plan policies
• Able to interpret and apply plan documents to ensure accurate claims adjudication
• Experience with 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

Pay, Benefits, and Schedule

• Individual compensation will be commensurate with the candidate's experience and qualifications.
• Certain roles may be eligible for additional compensation, including bonuses, and merit increases.
• Sales commissions are based on the terms of the sales commission plan applicable to the role.
• Pay Transparency: $19 - $22 USD
• Comprehensive medical, dental, vision, and life insurance coverage
• 401(k) retirement plan with employer match
• Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
• Paid time off (PTO) and disability leave
• Employee Assistance Program (EAP)

Equal Employment Opportunity

Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.