Remote Claims Examiner: Complex & High-Impact Claims

Capital District Physicians’ Health Plan, Inc.; Town of De Witt (NY); Hybrid; USD 42,000 - 68,000; Full time

Job summary

Capital District Physicians’ Health Plan, Inc. is seeking a Claims Examiner to process and adjudicate claims across Level I–IV, handling front‑end transactions, eligibility checks, and complex adjustments as responsibilities expand.

The role requires a high school diploma, prior claims or customer service experience, strong attention to detail, and NYS Independent Adjuster License; occasional remote work may be available on a case‑by‑case basis.

Qualifications

• High School diploma or equivalent required.
• Relevant customer service or claims processing experience preferred
• Capacity to continuously develop skills necessary for growth.
• Basic computer required, including the ability to navigate in a Windows environment.
• Able to work between multiple programs and applications at the same time.
• Assigned tasks/duties performed under the guidance of a lead or supervisor.
• Adept at multi-tasking to efficiently resolve moderately complex claims processing and simple adjustment transactions.
• NYS Independent Adjuster License and renewals required.

Responsibilities

• Handle front end transactions including member eligibility, entry of claims, member & provider matching and claim processing.
• Identify patterns that impact quality, claim inventory, and/or the customer experience and escalates for review.
• Identify potential trends and if necessary, elevate for investigation/solution.
• Process, enter, adjudicate and/or adjust and research claims; request needed information.
• Work closely with other required internal departments; collaborate with internal/external customers.
• Maintain member privacy per corporate policies; adhere to desk procedures.
• Perform other functions as assigned by management.

Skills

Customer service

Claims processing

Multi-tasking

Attention to detail

Problem solving

Education

High School diploma

NYS Independent Adjuster License

Tools

Windows environment

Multiple programs/applications

Job description

Capital District Physicians’ Health Plan, Inc. is seeking a Claims Examiner to process and adjudicate claims across Level I–IV, handling front‑end transactions, eligibility checks, and complex adjustments as responsibilities expand.

The role requires a high school diploma, prior claims or customer service experience, strong attention to detail, and NYS Independent Adjuster License; occasional remote work may be available on a case‑by‑case basis.