Claims Examiner

Job Description

Job Description

Responsible for the oversight and timely/accurate claims adjudication for all clients assigned. Claim types would include but may not be limited to data entry, dental, professional and/or institutional.

Must maintain a minimum of three consecutive months of production, quality and attendance after completing training in order to be eligible for a Claims Examiner II position. This is a remote work position.

EXAMPLES OF DUTIES:

• Responsible for accurately processing EDI Errors. 
• Processing the different claims types to include Institutional, Professional and Dental Claims.
• Review, research, and resolve claims in accordance with contracts and policies through the utilization of reference materials and on-line tools.
• Consistently maintains department minimum productivity and quality standards for adjudicating claims while maintaining established accuracy guidelines. 
• Must comply with strict privacy, integrity, confidentiality, availability and maintenance of Protected Health Information.
• Provide feedback to the unit Manager regarding plan benefits, Benefit Quoting Tool (BQT) and system issues.
• Processing all levels of claims procedures to include: Action Requests, Correspondence, Audit and Quality (AQ) work items and claim adjustments. 
• Consistently maintains department minimum productivity and quality standards for adjudicating claims while maintaining established accuracy guidelines. 
• Other projects as assigned.

QUALIFICATIONS:

• High School Diploma or equivalent
• Basic computer skills/ Word processing/ Windows operative system and Google Workspace experience preferred.
• 1-2 years healthcare industry experience 
• CPT, ICD-10, & HCPCS proficiency

PHYSICAL REQUIREMENTS:

• Sight within normal ranges, with or without use of corrective lenses.
• Finger dexterity. 
• Ability to be stationary for long periods of time.
• Ability to lift 10 to 15 pounds

Access to PHI:

• Routine & re-occurring access to all forms of PHI – The duties of the position require regular and unrestricted contact with PHI.
• Routine and limited and does not require manager approval - The duties of the position require routine contact with a limited set of PHI that does not require manager approval. Examples include claims adjudication. 
• Restricted and limited to manager approval on an as needed basis – Access to PHI is flexible and limited to a need to know basis pre-determined by the manager/supervisor depending on the nature of the task to be performed by this position. 
• Subject to incidental PHI disclosure – The position will at times come in contact with PHI that cannot be prevented, is limited in nature, and that occurs as a result of another permitted use or disclosure. Examples include proximity to areas where PHI is accessed or discussed.
• No PHI is accessed to perform the duties of the position – The position without exception has no job requirements involving the access to PHI.

ABOUT FIRST CHOICE HEALTH:

First Choice Health, headquartered in Seattle, WA, is a provider-owned healthcare organization offering employers a forward-thinking alternative to traditional health insurance. We have been serving employers of all sizes and across many industries with exceptional health benefits administration for over 35 years, providing unparalleled access to a growing number of clinically integrated networks (CIN) and a traditional PPO. Alongside our Employee Assistance Program (EAP) addressing mental health and work-life balance, our services collectively support members in every step of their healthcare journeys.
At First Choice Health, we are proud to deliver the personalized, quality service our clients deserve, while reducing costs and keeping their members healthy.
OUR PURPOSE, VALUES & CULTURE:
Uniting providers, employers, and individuals, we deliver sustainable solutions that elevate the health and care of our communities.

CARE TRANSPARENT COLLABORATE RELENTLESS INNOVATE

We strive to uphold the above values and take steps to cultivate our culture through each one. We work as a community, guided by our values and are unified in our mission to make healthcare access easier for everyone from all walks of life. Learn more about how we foster a culture of belonging.

At First Choice Health, we believe that a culture that fosters  belonging- one that accept employees for who they are, nurtures creative thinking, and appreciates different perspectives drives our success. By cultivating an environment where every voice is valued, we empower our employees to bring their best selves to work, enable us to serve our clients and communities more effectively. We work as a community, guided by our values and are unified in our mission to make healthcare access easier for everyone from all walks of life.

BENEFITS:
FCH offers comprehensive benefits focused on supporting employee health, financial security, and work-life balance.

• Health & Insurance: Medical (HSA and PPO plans) and Vision coverage, Dental plan, employer-provided Life Insurance, and Short- & Long-Term Disability coverage.
• Financial & Retirement: Health Savings Account (HSA) with company contributions, Flexible Spending Account (FSA), 401(k) plan with an employer match, and discretionary Profit Sharing.
• Time Off & Development: Paid Time Off (PTO) accrued based on tenure, Paid Holidays (including floating holidays and time for community service), and Tuition Reimbursement for continuing education.
• Support: Employee Assistance Program (EAP) for confidential professional counseling, and a Wellness program with rewards.

Note: Benefits are subject to change with or without notice.

Routine and limited and does not require manager approval - The duties of the position require routine contact with a limited set of PHI that does not require manager approval. Examples include claims adjudication.

For California employees, please review Privacy Act: