Claims Examiner (Remote, Remote, US)
Job Title: Claims Examiner
Job Type:Full Time
FLSA Status: Non-Exempt/Hourly
Grade: H
Function/Department: Health Plan and Healthcare Services
Reporting to: Team Lead/Supervisor - Operations
Pay Range: $16/hr & Matrix pay after training
Role Description: The Claims Examiner evaluates insurance claims to determine whether their validity and how much compensation should be paid to the policyholder. The Claims Examiner is responsible for reviewing all aspects of the claim, including reviewing policy coverage, damages, and supporting documentation provided by the policyholder.
Roles & Responsibilities
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Review insurance claims to assess their validity, completeness, and adherence to policy terms and conditions.
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Collect, organize, and analyze relevant documentation, such as medical records, accident reports, and policy information.
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Ensure that claims processing aligns with the company's insurance policies and relevant regulatory requirements.
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Conduct investigations, when necessary, which may include speaking with claimants, witnesses, and collaborating with field experts.
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Analyze policy coverage to determine the extent of liability and benefits payable to claimants.
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Evaluate the extent of loss or damage and determine the appropriate settlement amount.
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Communicate with claimants, policyholders, and other stakeholders to explain the claims process, request additional information, and provide status updates.
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Make recommendations for claims approval, denial, or negotiation of settlements, and ensure timely processing.
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Maintain accurate and organized claim files and records.
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Stay updated on industry regulations and maintain compliance with legal requirements.
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Provide excellent customer service, addressing inquiries and concerns from claimants and policyholders.
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Strive for high efficiency and accuracy in claims processing, minimizing errors and delays.
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Stay informed about industry trends, insurance products, and evolving claims management best practices.
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Generate and submit regular reports on claims processing status and trends.
- Perform other duties as assigned.
Top of Form
Qualifications
The qualifications listed below are representative of the background, knowledge, skill, and/or ability required to perform their duties and responsibilities satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.
Top of FormEducation
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High School diploma or equivalent required
Work Experience
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Health claims processing experience [referred] [required], including use of claims processing software and related tools
Competencies & Skills
- Highly-motivated and success-driven
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Exceptional verbal and written communication and interpersonal skills, including negotiation and active-listening skills
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Exceptional analytical and problem-solving skills
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Strong attention to detail with a commitment to accuracy
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Ability to adapt to change in a dynamic fast-paced environment with fluctuating workloads
- Basic mathematical skills
- Intermediate typing skills
- Basic computer skills
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Knowledge of medical terminology, ICD-9/ICS-10, CPT, and HCPCS coding, and HIPAA regulations preferred
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Knowledge of insurance policies, regulations, and best practices preferred
Additional Qualifications
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Ability to download 2-factor authentication application(s) on personal device, in accordance with company and/or client requirements
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Ability to pass the required pre-employment background investigation, including but not limited to, criminal history, work authorization verification and drug test
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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