Claims Examiner

About the role

The Claims Examiner is responsible for verifying, adjusting, and resolving insurance claims. The individual in this role serves clients and providers by ensuring claims are processed accurately, efficiently, and in compliance with company policies and regulatory requirements.

Responsibilities

• Reviews and validates claims for accuracy, completeness, and eligibility based on policy terms and guidelines.
• Analyzes, adjudicates, and resolves claims by approving or denying documentation, calculating benefit amounts, and initiating payments or composing denial letters.
• Safeguards legal compliance with company policies, procedures, and applicable state and federal regulations throughout the claims process.
• Maintains accurate records of claims, settlements, denials, and related documentation.
• Addresses questions and concerns from providers, clients, and internal personnel regarding the adjudication process.
• Reports overpayments, underpayments, and irregularities to supervisors.
• Communicates with reinsurance brokers and other stakeholders to obtain necessary information for claim processing.
• Verifies member eligibility, benefit coverage, and authorizations as needed.
• Protects confidential information and ensures HIPAA compliance.
• Identifies documentation gaps or discrepancies and coordinates resolution as needed.
• Supports quality, accuracy, and consistency in claims processing through adherence to policies and procedures.
• Effectively utilizes available technology and tools, including emerging and AI-enabled solutions, to support efficient workflows, accuracy, and a positive client service experience.
• Performs special projects and other duties as assigned.

Requirements

• A high school diploma or equivalent required.
• Minimum 1 year of healthcare reimbursement or claims processing experience.
• Intermediate computer skills, including email, database activity, word processing, and spreadsheets.
• Ability to handle multiple tasks simultaneously and adapt to changing priorities.
• Strong analytical, problem-solving, and communication skills.

Qualifications

• High school diploma or equivalent required.
• Minimum 1 year of healthcare reimbursement or claims processing experience.
• Intermediate computer skills, including email, database activity, word processing, and spreadsheets.
• Ability to handle multiple tasks simultaneously and adapt to changing priorities.
• Strong analytical, problem-solving, and communication skills.

Skills

• Strong analytical and problem-solving skills.
• Effective communication skills.
• Intermediate computer skills.
• Ability to handle multiple tasks simultaneously.

Benefits

Relation Insurance Inc. offers a competitive salary, a safe and healthy work environment, and a comprehensive benefits package including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays, and more. Career advancement and development opportunities are also available.

Pay

$15.38 - $32.21 per hour

Schedule

Full-time position.