Claims Examiner - TPA

About the role

Relation Insurance is a leading, innovative company with a strong commitment to excellence and a passion for delivering cutting‑edge solutions to clients. As a key player in the insurance market, we pride ourselves on our dynamic culture, collaborative environment, and continuous drive for success. With a rich history and a bright future ahead, we are looking for exceptional individuals to join our team and contribute to our ongoing growth and success.

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.
• Ensures 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 ensure 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.
• Special projects and other duties as assigned.

Qualifications

• High school diploma or equivalent required.
• Minimum 1 year of healthcare reimbursement or claims processing experience.

Skills

• Ability to read, analyze, and interpret company guidelines, benefit documentation, and government regulations.
• 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.

Benefits

• Safe and healthy work environment provided by our robust benefit program including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays and more.
• Career advancement and development opportunities.

Pay

Competitive pay with a wage range of $19.00 - $29.33 per hour.

Eligibility to participate in a discretionary annual incentive program, where an award depends on individual and organizational performance.