Claims Examiner

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration to strengthen integrated partnerships, advance market opportunities, and improve outcomes for patients and members. Founded in 1993 and acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014, Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. The organization is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

About the role

The Claims Examiner is a detail-oriented role responsible for reviewing and adjudicating health insurance claims across all products and lines of business, including Medicare, Self-Funded, and Fully Insured. This position ensures accuracy, compliance with policies and regulations, and timely settlements. Responsibilities include assessing claims, verifying information, and communicating effectively with internal stakeholders, members, providers, and other insurance companies.

About Universal Health Services

Universal Health Services, Inc. (UHS) is one of the nation’s largest and most respected providers of hospital and healthcare services. UHS operates acute care hospitals, behavioral health facilities, outpatient centers, ambulatory care access points, an insurance offering, a physician network, and various related services across the U.S., Washington, D.C., Puerto Rico, and the United Kingdom.

Responsibilities

• Review and adjudicate health insurance claims for accuracy and compliance with policies and regulations.
• Assess claims across all lines of business, including Medicare, Self-Funded, and Fully Insured.
• Verify claim information and ensure timely settlements.
• Communicate effectively with internal stakeholders, members, providers, and other insurance companies.

Requirements

• High school diploma or equivalent required; Associate degree in healthcare administration, Business Administration, or related field preferred.
• Two years’ experience as a Health Insurance Claims Examiner or similar role in the insurance industry preferred.
• In-depth knowledge of medical terminology, coding systems (ICD-10, CPT, HCPCS), and healthcare billing procedures.
• Familiarity with health insurance policies, regulations, and compliance standards.
• Strong analytical skills with attention to detail and accuracy in claims processing.
• Excellent communication and interpersonal abilities.
• Proficiency in claims processing software and Microsoft Office Suite.
• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.
• Certification in Health Insurance Portability and Accountability Act (HIPAA) compliance is a plus.
• Strong commitment to confidentiality and ethical conduct in handling sensitive healthcare data.