Claims Examiner: Self-Funded Benefits Expert

Pointchealth; Bellingham (WA); Hybrid; USD 26,000 - 30,000; Full time

Benefits offered by this job

Medical, dental, vision, and life-ins.

401(k) with employer match

HSA & FSAs

PTO & disability leave

EAP

Job summary

Point C Health is seeking a detail-oriented Claims Examiner to accurately process medical claims in a self-funded/TPA environment. The role requires analyzing plan documents, applying CPT/ICD-10 coding, and maintaining confidentiality while delivering timely results.

You will adjudicate new claims, handle adjustments and denials, review appeals, and manage daily inventory to meet production goals. Prior experience in health claims is essential, with proficiency in HealthPac, El Dorado, Javelina,

Qualifications

• Experience in TPA or self-funded claims administration preferred
• Minimum 2+ years in insurance claims processing required
• Experience finalizing claim payments per plan policies
• Ability to interpret and apply plan documents for adjudication
• Understanding of claim review processes and benefit plan design
• Experience with HealthPac, El Dorado, Javelina or VBA systems preferred
• Working knowledge of CPT and ICD-10 coding
• Basic medical terminology knowledge
• Strong communication and customer service skills
• Proficiency in Microsoft Office and general computer applications
• Ability to maintain confidentiality and follow company policies
• Able to work independently with minimal supervision
• Ability to prioritize, multitask, and work overtime
• Associate Degree preferred

Responsibilities

• Adjudicate new claims and process adjustments, including denials when info is missing
• Review and resolve appeals and subrogation/third-party liability cases
• Manage individual inventory to meet turnaround and production goals
• Ensure claims comply with stop loss contract terms
• Respond to inquiries via email and other channels within timeframes
• Follow up on missing or incomplete information for accurate processing
• Maintain minimum production, financial, and procedural accuracy monthly

Skills

TPA experience

2+ years claims processing

claims adjudication

interpret plan documents

benefit plan design

HealthPac/El Dorado/Javelina/VBA

CPT & ICD-10 coding

medical terminology

customer service

MS Office

confidentiality

independent work

multi-task & overtime

Associate Degree preferred

Education

Associate Degree

Tools

HealthPac

El Dorado

Javelina

VBA

Job description

Point C Health is seeking a detail-oriented Claims Examiner to accurately process medical claims in a self-funded/TPA environment. The role requires analyzing plan documents, applying CPT/ICD-10 coding, and maintaining confidentiality while delivering timely results.

You will adjudicate new claims, handle adjustments and denials, review appeals, and manage daily inventory to meet production goals. Prior experience in health claims is essential, with proficiency in HealthPac, El Dorado, Javelina,