Claims Examiner II

HealthEdge Software, Inc.; Northern (KY); Hybrid; USD 48,712,000 - 54,443,000; Full time

Job summary

HealthEdge is seeking a Claims Examiner II to adjudicate healthcare claims, applying CPT, HCPCS, ICD-10 coding and client guidelines in a fast-paced remote environment. You will determine coverage and payment decisions, review edits, and support accuracy across multiple time zones.

We value accuracy, collaboration, and a willingness to learn. This role offers full-time, remote work with opportunities to mentor peers and contribute to process improvements within UST HealthProof.

Qualifications

• 1–3 years healthcare claims processing experience.
• Solid understanding and ability to analyse claim data.
• Familiarity with ICD-10 CPT and HCPCS coding advantageous.

Responsibilities

• Process assigned claims based on client guidelines or team lead directions.
• Meet productivity targets and accuracy standards set by management.
• Mentor junior team members.
• Collaborate on special projects such as process documentation or quality audits.
• Maintain knowledge of physician practices, coding, and medical terminology.
• Communicate with management to address issues and ensure quality.

Skills

claims processing

ICD-10 CPT HCPCS coding

Willingness to learn

Team collaboration

Strong work ethic

Education

High School degree

Job description

Overview

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.

At UST HealthProof, you will join a fast paced, growing company in our mission to reshape the future of health insurance through significantly reducing administrative costs and building better healthcare experiences for our health plans customers and their members. By creating a modern, cloud based, Best-In-Class core administration ecosystem, we have made healthcare more affordable and helped our health plans operate more efficiently. Through member and provider touchpoints with less friction, we have created real impact for members.

UST HealthProof is run by leaders with strong health plan and technology backgrounds who have start-up mindsets and an environment of support where individual growth is nurtured. You will be supporting our proven core admin solutions and business process-as-a-service (BPaaS) operations to provide transparency, improve operational efficiency, and break down operational barriers to scale and drive strategic growth.

UST HealthProof is looking for Claims Examiner II, reporting to the Claims Team Leader. The Claims Examiner II is responsible for the adjudication of healthcare claims utilizing specific policies and procedures. This role is responsible for reviewing data within the claims processing system, to determine if services rendered were appropriate and benefit coverage criteria were met. The Claims Examiner II is accountable for reviewing the adjudication system edits to determine whether to pay the claim and/or line item(s).

As a Claims Examiner II at UST HealthProof, this is your opportunity to

• Be responsible for processing assigned claims based on client-specified guidelines or as directed by the team leader
• Be responsible for meeting productivity targets, financial and procedural accuracy standards as established by management
• Mentor junior members of the team
• Collaborate with other team members on special projects as assigned by the team leads; special projects can include process documentation development, training, quality audits, assisting with surge activity for the client(s), or any other project as determined by the team leader
• Knowledge base around physician practices and hospital coding, billing and medical terminology, CPT, HCPCS, and ICD-10, UB04, CMS 1500, authorizations, medical terminology, and concepts of healthcare
• Establish and maintain an appropriate level of communication with management to address issues and concerns and take preventive measures that ensure processing accuracy and quality
• Participate in projects assigned by the team leader; these projects may include provider data, authorizations, enrollment, or other activities

You bring:

• High School degree required
• 1 – 3 years healthcare claims processing experience
• Solid understanding and ability to analyse claim data
• ICD-10 CPT and HCPCS coding, is a plus
• Willingness to learn new skills
• Team collaborator
• Strong work ethic

For this role, we value:

• The ability to adapt quickly to a fast-paced environment
• A self-starter and quick learner
• Team player with an ability to collaborate

Geographic Responsibility: Remote, US

Type of Employment: Full-time, permanent

Work Environment: 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:

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

• Work across multiple time zones in a hybrid or remote work environment.

• Long periods of time sitting and/or standing in front of a computer using video technology.

• May require travel dependent on company needs.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

#LI-Remote

** The annual US hourly range for this position is $17.00 to $19.00/hr. This salary range may cover multiple career levels at HealthEdge. Final compensation will bedeterminedduring the interview process and is based on a combination of factors including, but not limited to,your skills, experience,qualificationsand education.