Claims Examiner I

Full-Time Claims Examiner I

Capital Health Plan is looking for a full-time Claims Examiner I to join our team in Tallahassee, FL. In this full-time role, you will help ensure insurance claims are reviewed, evaluated, and processed accurately according to departmental policies, provider agreements, and member benefits.

This is a full-time position working Monday through Friday from 8:00 AM to 5:00 PM. Team members must also be willing to work evenings, weekends, and overtime as directed.

All that you need is:

• High school diploma or equivalent or one to three months of related experience and/or training or an equivalent combination of education and experience
• Ability to read and interpret safety rules, operating and maintenance instructions, and procedure manuals
• Ability to write routine reports and correspondence
• Ability to communicate effectively with customers and employees
• Basic math skills and ability to compute rates, ratios, and percentages and interpret bar graphs
• Ability to carry out detailed written or verbal instructions
• Ability to solve problems involving a few concrete variables in standardized situations
• Knowledge of, or ability to learn, industry-standard procedure and diagnosis codes
• Knowledge of, or ability to learn, medical terminology
• Skilled in the use of, or ability to learn, Microsoft Outlook, Word, and Excel
• Working knowledge of, or ability to learn, Adobe Acrobat software
• Ability to meet and maintain state, federal, and CHP guidelines and standards for timeliness and accuracy of claims processing
• Ability to read, understand, and interpret claim editing documentation and healthcare regulatory information
• Ability to occasionally lift and/or move up to 25 pounds

What can you expect as our Claims Examiner I?

As a Claims Examiner I, you will analyze insurance claims of low to moderate difficulty to determine Capital Health Plan's liability and adjudicate claims in accordance with departmental policies and provider agreements. Your day will include reviewing claims for errors or missing information, evaluating claims for payment based on provider agreements and member benefits, and issuing appropriate denial notifications when necessary. You will follow up on pending claims, work with other departments to resolve outstanding issues, maintain processing statistics, and notify the Claims Supervisor when pending claims exceed established limits. You will also perform data validation on scanned and OCR claims, enter information from paper claims, and refer questionable claims for further review. Success in this role will be measured by your ability to meet standards for production, accuracy, and customer service while progressing to more complex claims within six months.

A little bit more about us

We are a not-for-profit health care organization that has served the panhandle since 1982, delivering high-quality, affordable, and patient-centered care. Our employees are essential to our continued success, and their passion, motivation, and commitment drive our reputation for excellence and member satisfaction.

Whether delivering direct care, supporting patients, or ensuring smooth operations behind the scenes, every team member plays a vital role in fulfilling our mission to improve the health of our communities. We are dedicated to fostering a professional, respectful, and inclusive workplace where employees are valued, supported in their growth, and empowered to make a meaningful impact.