Claims - Examiner, Claims

Wellcove CHCS Services; United States; Remote; USD 42,000 - 64,000; Full time

Job summary

Wellcove CHCS Services is seeking a detail-oriented claims adjudicator to manage outbound calls and adjudicate HP/AD claims. The role involves research, independent analysis of medical documents, and timely action within client guidelines.

Candidates should understand ICD-10, CPT, revenue codes, and HIPAA regulations, with strong English comprehension and math skills. You will work remotely with strict privacy and quality standards across the US.

Qualifications

• Experience with US HIP claims
• Strong medical terminology knowledge
• Ability to interpret medical documents and codes

Responsibilities

• Adjudicating HP/AD claims
• Handling all outbound calls
• Prioritize work and adjudicate claims within turnaround times
• Researching, reviewing, summarizing, and recommending actions on claims with appeals or grievances
• Comprehend medical reports using English, basic math and medical knowledge
• Ensure claims adjudication per client and company guidelines
• Respond to and resolve claims via email
• Calculate claim amounts for customers accurately
• Comply with HIPAA, confidentiality and privacy requirements

Skills

Medical terminology

English comprehension

Analytical skills

Attention to detail

Remote work capability

Education

Experience in US HIP claims

Tools

ICD-10

CPT

Revenue codes

Job description

Who We Are

Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs. Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology.

Job Summary

Manage and handle all Outbound calls and adjudicate claims.

Duties/Responsibilities

• Adjudicating HP/AD claims
• Handling all Outbound calls
• Should be able to prioritize work and adjudicate claims as per turnaround time
• Job involves working independently on researching, reviewing, summarizing, and recommending a course of action on claims where an appeal or a grievance has been filed for a denied / under payment
• Should have strong English comprehension, mathematics & medical science knowledge to comprehend medical reports
• To ensure claims are adjudicated as per the client/company guidelines.
• Provide continual evaluation of processes and procedures.
• To respond to and resolves claims received via emails.
• Candidate should be able to correctly calculate claim amounts for the customers
• Complying with company regulations regarding HIPAA, confidentiality, and private health information

Standard Company Requirements

• Collaborative team spirit.
• Accountable and able to work remotely and independently.
• Able to pass background screening and drug tests pre and post hire – includes THC Verification of high school, GED, or college diploma upon request.
• Timely responses from three professional references.
• Able to provide a dedicated remote work location free from background noises, interruptions, and desk clutter.
• Able to provide an ongoing reliable internet connection and access to a smart phone for Multi Factor Authentication and communication purposes.

Required Skills/Abilities

• Should have knowledge of medical terminology, human anatomy with basic math knowledge of calculating simple interest, compound interest.
• Should have excellent problem-solving skills with an eye for detail, to be able to do root cause analysis of complex claims
• Should have a positive approach and open to learning process dynamics
• Ready to handle work pressure and ensure deliverables within timelines

Education and Experience

• Experience in handling US HIP claims
• Should have knowledge of ICD 10, CPT, Surgery procedures, Revenue codes, medical terminology, medical documents, Inpatient vs Outpatient claims etc.
• Should have some experience in reading and comprehending medical documents

At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability.