Claims Examiner II - Provider Projects

About the role

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations that helps customers achieve affordable, equitable health care for all.

The Claims Examiner II is responsible for the adjudication of healthcare claims utilizing specific policies and procedures. This role reviews data within the claims processing system to determine if services rendered were appropriate and benefit coverage criteria were met.

Responsibilities

• 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 such as process documentation development, training, quality audits, assisting with surge activity for the client(s), or other projects as determined by the team leader.
• Apply knowledge of physician practices and hospital coding, billing and medical terminology, including CPT, HCPCS, ICD-10, UB04, CMS 1500, authorizations, and concepts of healthcare.
• Establish and maintain appropriate communication with management to address issues and concerns, taking preventive measures to ensure processing accuracy and quality.
• Participate in projects assigned by the team leader, which may include provider data, authorizations, enrollment, or other activities.

Requirements

• Solid understanding and ability to analyze claim data.
• Knowledge of ICD-10, CPT, and HCPCS coding (a plus).
• High School degree required.
• 1–3 years of healthcare claims processing experience.
• Willingness to learn new skills.
• Strong team collaboration and work ethic.

Skills

• Ability to adapt quickly to a fast-paced environment.
• Self-starter and quick learner.
• Team player with strong collaboration skills.

Pay

The annual US base salary range for this position is $40,000 to $44,000. Final compensation will be determined during the interview process and is based on factors including skills, experience, qualifications, and education.

Schedule

This is a full-time, permanent role. The work environment is remote within the US.

The role may require occasional movement around the office, long periods of sitting or standing in front of a computer, and the use of video technology. Work may span multiple time zones in a hybrid or remote setting. Travel may be required dependent on company needs.