Claims Examiner II - Provider Projects

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. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology.

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations that helps our customers achieve affordable, equitable health care for all. We have a strong global presence, with a workforce of over 4,000 people built on a foundation of simplicity, integrity, people-centricity, and leadership.

About the role

The Claims Examiner II is responsible for the adjudication of healthcare claims utilizing specific policies and procedures. This role involves reviewing 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 as assigned by the team leads; special projects can include process documentation development, training, quality audits, assisting with surge activity for the client(s), or any other project as determined by the team leader
• Develop knowledge base around physician practices and hospital coding, billing and medical terminology, CPT, HCPCS, ICD-10, UB04, CMS 1500, authorizations, medical terminology, and concepts of healthcare
• Establish and maintain an appropriate level of communication with management to address issues and concerns and take preventive measures that ensure processing accuracy and quality
• Participate in projects assigned by the team leader; these projects may include provider data, authorizations, enrollment, or other activities

Requirements

• Solid understanding and ability to analyze claim data
• ICD-10, CPT, and HCPCS coding is a plus
• High School degree required
• 1 – 3 years healthcare claims processing experience
• Willingness to learn new skills
• Team collaborator with a strong work ethic

Skills

• Ability to adapt quickly to a fast-paced environment
• Self-starter and quick learner
• Team player with an ability to collaborate

Work Environment

• The employee is occasionally required to move around the office
• Specific vision abilities required include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus
• Work across multiple time zones in a hybrid or remote work environment
• Long periods of time sitting and/or standing in front of a computer using video technology
• May require travel dependent on company needs

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 a combination of factors including, but not limited to, your skills, experience, qualifications, and education.