Claims Examiner

About This Role

This Claims Examiner role involves verifying, adjudicating, and resolving insurance claims, ensuring accurate and efficient processing in compliance with company policies and regulations. The individual will serve clients and providers by addressing questions and concerns related to the adjudication process.

Responsibilities

• Review and validate claims for accuracy, completeness, and eligibility based on policy terms and guidelines
• Analyze, adjudicate, and resolve claims by approving or denying documentation, calculating benefit amounts, and initiating payments or composing denial letters
• Ensure legal compliance with company policies, procedures, and applicable state and federal regulations throughout the claims process
• Maintain accurate records of claims, settlements, denials, and related documentation
• Address questions and concerns from providers, clients, and internal personnel regarding the adjudication process
• Report overpayments, underpayments, and irregularities to supervisors
• Communicate with reinsurance brokers and other stakeholders to obtain necessary information for claim processing
• Verify member eligibility, benefit coverage, and authorizations as needed
• Protect confidential information and ensure HIPAA compliance
• Participate in process improvement initiatives and update documentation as required

Requirements

• High school diploma or equivalent
• 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

Qualifications

• High school diploma or equivalent required, Associate’s degree or technical college coursework preferred.
• 1-3 years of healthcare reimbursement, claims processing, or customer service experience preferred. Experience in provider contract development, medical billing/coding, patient accounting, claims auditing, or revenue cycle improvement.

Nice to Have

• Associate’s degree or technical college coursework
• 1-3 years of healthcare reimbursement, claims processing, or customer service experience
• In-depth knowledge of medical coding principles
• Familiarity with Medicaid, Medicare, and commercial insurance claims
• Experience in provider contract development, medical billing/coding, patient accounting, claims auditing, or revenue cycle improvement

Benefits