Claims Examiner

Firstsource; Dallas (TX); Hybrid; USD 55,000 - 70,000; Full time

Job summary

Firstsource Solutions is seeking a Claims Examiner in Dallas to analyze documents and determine payment or denial of claims submitted by members or providers, following client specifications.

The full-time, non-exempt role supports the Health Plan and Healthcare Services unit, with on-site or remote work options, requiring strong analytical, written and verbal communication, attention to detail, and teamwork to meet TAT and quality SLAs.

Qualifications

• Must have high school diploma or equivalent.
• Strong analytical and problem-solving abilities required.
• Excellent verbal and written communication skills.
• Ability to adhere to HIPAA regulations and data privacy.
• Familiarity with medical terminology and coding is preferred.

Responsibilities

• Analyze claims based on rules and workflows to approve or deny.
• Route claims to other departments for missing information.
• Ensure claims adjudication within required TAT and SLA.

Skills

Analytical skills

Verbal & written communication

Medical terminology knowledge

Typing skills

Detail-oriented

Adaptability

Education

High School diploma or equivalent

Job description

Job Title:Claims Examiner

Job Type: Full Time

FLSA Status: Non-Exempt/Hourly

Grade: H2

Function/Department: Health Plan and Healthcare Services

Reporting to: Team Lead/Supervisor - Operations

Role Description: A claims examiner needs to analyse multiple documents / contracts and decide to pay / deny the claim submitted by member or providers with respect to client specifications. The claims examiner should also route the claim to different department or provider / member for any missing information that required for claims adjudication. The claims need to be completed adhering to required TAT and quality SLA.

Key Responsibilities

• Should have Excellent Analytical skills to review claims based on rules and workflows.
• Need good comprehension skills to adjudicate claims as per Policies and Procedures.
• Should be a complete team player

Key Performance Indicators:

• * Ensuring that the key Service Level Agreements are met consistently without any exceptions.
• * Achieve set Production goals.
• * Adherence to departmental and company rules and regulations.

Qualifications

The qualifications listed below are representative of the background, knowledge, skill, and/or ability required to perform their duties and responsibilities satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

Education

• High School diploma or equivalent required

Competencies & Skills

• Highly-motivated and success-driven
• Exceptional verbal and written communication and interpersonal skills, including negotiation and active-listening skills
• Exceptional analytical and problem-solving skills
• Strong attention to detail with a commitment to accuracy
• Ability to adapt to change in a dynamic fast-paced environment with fluctuating workloads
• Basic mathematical skills
• Intermediate typing skills
• Basic computer skills
• Knowledge of medical terminology, ICD-9/ICS-10, CPT, and HCPCS coding, and HIPAA regulations preferred
• Knowledge of insurance policies, regulations, and best practices preferred

Additional Qualifications

• Ability to download 2-factor authentication application(s) on personal device, in accordance with company and/or client requirements
• Ability to pass the required pre-employment background investigation, including but not limited to, criminal history, work authorization verification and drug test

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position may work onsite or remotely from home.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Must be able to regularly or frequently talk and hear, sit for prolonged periods, use hands and fingers to type, and use close vision to view and read from a computer screen and/or electronic device. Must be able to occasionally stand and walk, climb stairs, and lift equipment up to 25 pounds.

Firstsource is an Equal Employment Opportunity employer. All employment decisions are based on valid job requirements, without regard to race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, age, disability, genetic information, veteran status, or any other characteristic protected under federal, state or local law.

Firstsource also takes Affi

About Firstsource

Firstsource Solutions is a leading provider of customized Business Process Management (BPM) services. Firstsource specialises in helping customers stay ahead of the curve through transformational solutions to reimagine business processes and deliver increased efficiency, deeper insights, and superior outcomes.

We are trusted brand custodians and long-term partners to 100+ leading brands with presence in the US, UK, Philippines, India and Mexico. Our 'rightshore' delivery model offers solutions covering complete customer lifecycle across Healthcare, Telecommunications & Media and Banking, Financial Services & Insurance verticals.

Our clientele includes Fortune 500 and FTSE 100 companies.