Claims Examiner I

Western Growers; United States; Remote; USD 40,000 - 60,000; Full time

Job summary

A leading company in the healthcare sector is seeking a Claims Examiner I to review and process medical claims. This role requires strong analytical skills and knowledge of medical terminology. The Claims Examiner will ensure compliance with regulations while meeting productivity benchmarks. Ideal candidates will have experience in claims processing and excellent communication skills. This position offers a dynamic work environment with opportunities for professional growth.

Qualifications

• 1-3 years of experience as a Health Claims Examiner preferred.
• Basic knowledge of medical terminology and familiarity with claims forms.

Responsibilities

• Adjudicate various claim types including Dental, Vision, Medical.
• Verify claim accuracy and communicate with healthcare providers.
• Maintain HIPAA compliance and ensure confidentiality.

Skills

Communication

Problem-Solving

Data Entry

Medical Terminology

Education

High school diploma or equivalent

Tools

Microsoft Office Suite

Job description

JOB DESCRIPTION SUMMARY

The Claims Examiner I reports to the Supervisor of Claims. The Claims Examiner I is responsible for reviewing and processing medical, dental, vision, and electronic claims in accordance with state, federal, and health plan regulatory requirements, as well as departmental guidelines. The role includes meeting quality and production benchmarks, researching documentation, and processing Health Insurance Payment Demand (HIPD) claims.

The Claims Examiner I will thoroughly review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorizations, and process payments. The position also involves resolving issues from providers, customer service, member services, health plans, and other internal customers.

Qualifications

• High school diploma or equivalent; 1-3 years of experience as a Health Claims Examiner or similar industry experience preferred.
• Minimum of 1 year experience handling medical, dental, and vision claims, including subrogation and accident claims.
• Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication.
• Basic knowledge of medical terminology and familiarity with UB-04, HCFA 1500 forms, ICD-10, CPT, and HCPCS codes.
• Strong verbal and written communication skills.
• Proficient in 10-key data entry (40 WPM) and Microsoft Office Suite.
• Ability to work under pressure and adapt to changing environments.
• Knowledge of ERISA claims processing guidelines.

Duties and Responsibilities

• Adjudicate various claim types, including Dental, Vision, Medical, inpatient/outpatient, physician, in/out of network, Medicaid reclamation, outpatient labs, radiology, accident, and Third-Party Liability claims.
• Analyze patient and medical information to determine appropriate benefits, pricing, and authorizations.
• Verify claim accuracy, including eligibility and medical authorization, and communicate with healthcare providers for documentation.
• Resolve benefit and eligibility issues, process low-level claims, and perform re-pricing corrections.
• Complete all correspondence related to electronic and paper claims.
• Maintain HIPAA compliance and ensure confidentiality of protected health information.
• Meet individual and departmental productivity and quality standards.

Additional Responsibilities

• Exercise judgment and problem-solving skills to analyze data and make decisions.
• Ensure compliance with policies, practices, and regulations.
• Partner with peers to document requirements and identify improvements.
• Contribute to standard setting and review processes.
• Identify and escalate potential compliance issues.
• Make timely decisions based on available information.
• Collaborate with team members to resolve issues and improve processes.

Physical Demands and Work Environment

This role requires regular communication, movement around the office, and use of tools and controls. The noise level is usually moderate. Reasonable accommodations are available for individuals with disabilities.

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