Claims Examiner II
About the role
HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. The company is experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively.
HealthEdge is looking for a Claims Examiner II, reporting to the Claims Team Leader. The Claims Examiner II is responsible for the adjudication of healthcare claims utilizing specific policies and procedures, reviewing data within the claims processing system to determine if services were appropriate and benefit coverage criteria were met, and reviewing adjudication system edits to decide whether to pay the claim and/or line items.
The role may require occasional movement around the office, specific vision abilities (close, color, peripheral, depth perception, and focus adjustment), long periods of sitting or standing at a computer, work across multiple time zones in a hybrid or remote setting, and possible travel based on company needs.
Responsibilities
- Adjudicate healthcare claims by reviewing claim data to determine appropriateness of services and benefit coverage, and reviewing adjudication system edits to decide payment of claims or line items.
- Process assigned claims based on client‑specified guidelines or as directed by the team leader.
- Meet productivity targets, financial and procedural accuracy standards as established by management.
- Mentor junior members of the team.
- Collaborate with other team members on special projects as assigned by the team leads; special projects can include process documentation development, training, quality audits, assisting with surge activity