Claims Examiner II - Provider Projects

HealthEdge Software, Inc.; Northern (KY); Hybrid; USD 40,000 - 44,000; Full time

Job summary

HealthEdge Software, Inc. is seeking a Claims Examiner II to adjudicate healthcare claims remotely in the United States.

You will review data in the claims processing system to determine service appropriateness and whether benefits meet coverage criteria, reporting to the Claims Team Leader. Requirements include 1–3 years of healthcare claims processing experience, a High School diploma, and knowledge of ICD-10/CPT/HCPCS.

Qualifications

• 1–3 years healthcare claims processing experience.
• High School diploma required.
• Solid ability to analyze claim data.
• Familiarity with ICD-10, CPT & HCPCS coding is a plus.
• Team-oriented with a strong work ethic.

Responsibilities

• Process assigned claims based on client guidelines and team direction.
• Meet productivity targets and maintain accuracy standards.
• Mentor junior team members.
• Collaborate on special projects such as documentation, training, or quality audits.
• Maintain knowledge of physician practices, billing terms, CPT/HCPCS/ICD-10.

Skills

Claim data analysis

ICD-10 CPT HCPCS knowledge

Team collaboration

Strong work ethic

Willingness to learn

Healthcare claims processing

Education

High School diploma

Job description

Overview

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.

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations that helps our customers achieve affordable, equitable health care for all. We have a strong global presence, with a workforce of over 4,000 people built on a foundation of simplicity, integrity, people-centricity, and leadership.

You Are

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 Opportunity

• 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

What You Need

• Solid understanding and ability to analyze claim data
• ICD-10 CPT and HCPCS coding, is a plus
• High School degree required
• 1 – 3 years healthcare claims processing experience
• 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 employeeis occasionally required tomove 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 periodsof 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 skillsrequired. HealthEdge reserves the right tomodify, add, or remove duties and to assign otherdutiesas 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 maybe requiredto 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,veteransand persons with disabilities.

#LI-Remote

**The annual US base salary range for this position is $40,000 to $44,000. 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.