Claims Examiner - TPA

Edison Health Solutions, LLC; Tulsa (OK); On-site; USD 54,443,000 - 84,042,000; Full time

Job summary

Relation Insurance Inc. is seeking a Claims Examiner to verify, adjust, and resolve insurance claims in a fast-paced environment. The role emphasizes accuracy and regulatory compliance in processing claims.

The role involves reviewing eligibility, adjudicating payments, maintaining records, and communicating with providers and clients while protecting confidential information and ensuring HIPAA compliance. The ideal candidate will have at least 1 year in healthcare reimbursement or claims

Qualifications

• High school diploma or equivalent required.
• Minimum 1 year of healthcare reimbursement or claims processing experience.
• Ability to read, analyze, and interpret company guidelines, benefit documentation, and government regulations.
• Intermediate computer skills, including email, database activity, word processing, and spreadsheets.
• Ability to handle multiple tasks simultaneously and adapt to changing priorities.
• Strong analytical, problem-solving, and communication skills.

Responsibilities

• Reviews and validates claims for accuracy, completeness, and eligibility based on policy terms and guidelines.
• Analyzes, adjudicates, and resolves claims by approving or denying documentation, calculating benefit amounts, and initiating payments or composing denial letters.
• Ensures legal compliance with company policies, procedures, and applicable state and federal regulations throughout the claims process.
• Maintains accurate records of claims, settlements, denials, and related documentation.
• Addresses questions and concerns from providers, clients, and internal personnel regarding the adjudication process.
• Reports overpayments, underpayments, and irregularities to supervisors.
• Communicates with reinsurance brokers and other stakeholders to obtain necessary information for claim processing.
• Verifies member eligibility, benefit coverage, and authorizations as needed.
• Protects confidential information and ensures HIPAA compliance.
• Identifies documentation gaps or discrepancies and coordinates resolution as needed.
• Supports quality, accuracy, and consistency in claims processing through adherence to policies and procedures.
• Effectively utilizes available technology and tools, including emerging and AI-enabled solutions, to support efficient workflows, accuracy, and a positive client service experience.
• Special projects and other duties as assigned.

Skills

Interpersonal skills

Analytical skills

Organizational skills

Education

High school diploma or equivalent

Job description

WHO WE ARE

Relation Insurance is a leading, innovative company with a strong commitment to excellence and a passion for delivering cutting‑edge solutions to our clients. As a key player in the insurance market, we pride ourselves on our dynamic culture, collaborative environment, and continuous drive for success. With a rich history and a bright future ahead, we are looking for exceptional individuals to join our team and contribute to our ongoing growth and success.

WHAT WE’RE LOOKING FOR

The Claims Examiner is responsible for verifying, adjusting, and resolving insurance claims. The individual in this role serves clients and providers by ensuring claims are processed accurately, efficiently, and in compliance with company policies and regulatory requirements. The Claims Examiner must demonstrate strong interpersonal, analytical, and organizational skills, and be able to communicate effectively with a variety of stakeholders.

A GLIMPSE INTO YOUR DAY

Reviews and validates claims for accuracy, completeness, and eligibility based on policy terms and guidelines.

Analyzes, adjudicates, and resolves claims by approving or denying documentation, calculating benefit amounts, and initiating payments or composing denial letters.

Ensures legal compliance with company policies, procedures, and applicable state and federal regulations throughout the claims process.

Maintains accurate records of claims, settlements, denials, and related documentation.

Addresses questions and concerns from providers, clients, and internal personnel regarding the adjudication process.

Reports overpayments, underpayments, and irregularities to supervisors.

Communicates with reinsurance brokers and other stakeholders to obtain necessary information for claim processing.

Verifies member eligibility, benefit coverage, and authorizations as needed.

Protects confidential information and ensures HIPAA compliance.

Identifies documentation gaps or discrepancies and coordinates resolution as needed.

Supports quality, accuracy, and consistency in claims processing through adherence to policies and procedures.

Effectively utilizes available technology and tools, including emerging and AI-enabled solutions, to support efficient workflows, accuracy, and a positive client service experience.

Special projects and other duties as assigned.

WHAT SUCCESS LOOKS LIKE IN THIS ROLE

• High school diploma or equivalent required.
• Minimum 1 year of healthcare reimbursement or claims processing experience.
• Ability to read, analyze, and interpret company guidelines, benefit documentation, and government regulations.
• Intermediate computer skills, including email, database activity, word processing, and spreadsheets.
• Ability to handle multiple tasks simultaneously and adapt to changing priorities.
• Strong analytical, problem‑solving, and communication skills.

WHY CHOOSE RELATION?

• Competitive pay.
• A safe and healthy work environment provided by our robust benefit program including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays and more.
• Career advancement and development opportunities.

Note: The above is not all encompassing of the full position description.

Relation Insurance Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Relation, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is presented within this posting. You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various factors, including, without limitation, individual and organizational performance.

$19.00 - $29.33

Relation Insurance Services is a North American insurance brokerage that offers business insurance, Employee Benefits, Personal Insurance, Retirement Services, and Risk-management through our family of brands across the United States. More importantly, we’re a team of experienced professionals who genuinely care. Whether it’s for you, your family, or your business/organization, we want to be the relationship you trust for answers to your questions, solutions for your insurance needs, and peace of mind for your future.