Remote Claims Examiner — Growth Path I–IV

Capital District Physicians Health Plan Inc; Buffalo (NY); Hybrid; USD 28,000 - 45,000; Full time

Job summary

Capital District Physicians Health Plan Inc. is seeking a Claims Examiner to handle a broad range of claims transactions, including entry, adjudication, and adjustments in line with MTM, NCQA, and PIP policies.

The role progresses through four levels with increasing responsibility and independence, from Level I to Level IV, requiring attention to detail and strong collaboration. This position may offer remote work on a case-by-case basis as part of CDPHP's flexible work policy, with a

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.
• Effective self-management 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.
• B Version: Valid NYS Independent Adjuster License and continued administrative maintenance of renewals is 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 escalat for review.
• Identify potential trends and if necessary, escalat for investigation/solution.
• Process, enter, adjudicate and/or adjust and research claims according to procedures.
• Request needed information through system generated letters and/or phone calls.
• Work closely with other required internal departments.

Skills

Attention to detail

Communication skills

Multitasking

Education

High School diploma

Tools

Windows OS

Job description

Capital District Physicians Health Plan Inc. is seeking a Claims Examiner to handle a broad range of claims transactions, including entry, adjudication, and adjustments in line with MTM, NCQA, and PIP policies.

The role progresses through four levels with increasing responsibility and independence, from Level I to Level IV, requiring attention to detail and strong collaboration. This position may offer remote work on a case-by-case basis as part of CDPHP's flexible work policy, with a