Remote Research Claims Examiner

HCA Healthcare; Nashville (TN); On-site; USD 42,000 - 54,000; Full time

Benefits offered by this job

Health benefits

401(k) match

Work from home

Job summary

HCA Healthcare's Physician Services Group is seeking a Research Claims Examiner to ensure correct adjudication of claims for PPMSI contracted plans. This remote role supports processing high volumes from home.

You will analyze, resolve system edits, provide training, complete Excel reconciliations, and work with provider contracts and pricing. Strong attention to detail and knowledge of claims procedures are essential.

Qualifications

• Ability to communicate well with supervisors and co-workers.
• Ability to analyze claim issues and troubleshoot claims problems.
• Ability to work in high volume, production oriented environment.
• Detail oriented with an ability to sit for extended period of time.
• Ability to act as a resource and/or trainer for claims processors.
• Ability to work under demanding performance standards for production and quality.
• Technical competence with claims processing software.
• Ability to understand and implement complex claims procedures.
• Team player with ability to handle multiple projects.

Responsibilities

• Adjudicate recalculations, resolving all system edits and audits for hardcopy and electronic claims.
• Handle Case Log adjustment requests and resolve claims issues; identify root cause for errors and collaborate for resolution.
• Resolve provider and eligibility issues relating to received claims.
• Identify potential system programming issues and report to Manager.
• Provide technical support and training for claims examiners.
• Understand Plan contracts, provider pricing, member eligibility, referral authorization procedures, benefit plans and capitation arrangements and process claims accordingly.
• Complete excel spreadsheets for project reconciliation.
• Send written explanation to provider following completion of claim research.
• Complete Provider Dispute Resolution process in accordance with AB1455.
• Perform other duties as assigned.

Skills

Claim analysis

Communication

Detail oriented

Team training

High-volume environment

Claims software

ICD-9/CPT/HCPC knowledge

Medical terminology

DMHC/CMS/NCQA knowledge

Word & Excel

Education

High school diploma or equivalent

Tools

Claims processing software

Job description

HCA Healthcare's Physician Services Group is seeking a Research Claims Examiner to ensure correct adjudication of claims for PPMSI contracted plans. This remote role supports processing high volumes from home.

You will analyze, resolve system edits, provide training, complete Excel reconciliations, and work with provider contracts and pricing. Strong attention to detail and knowledge of claims procedures are essential.