Claims Examiner

About Firstsource 

Firstsource Solutions is a leading provider of customized Business Process Management (BPM) services. Firstsource specialises in helping customers stay ahead of the curve through transformational solutions to reimagine business processes and deliver increased efficiency, deeper insights, and superior outcomes. 

We are trusted brand custodians and long-term partners to 100+ leading brands with presence in the US, UK, Philippines, India and Mexico. Our ‘rightshore’ delivery model offers solutions covering complete customer lifecycle across Healthcare, Telecommunications & Media and Banking, Financial Services & Insurance verticals. 

Our clientele includes Fortune 500 and FTSE 100 companies.

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

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 

• Review insurance claims to assess their validity, completeness, and adherence to policy terms and conditions.

• Collect, organize, and analyze relevant documentation, such as medical records, accident reports, and policy information.

• Ensure that claims processing aligns with the company's insurance policies and relevant regulatory requirements.

• Conduct investigations, when necessary, which may include speaking with claimants, witnesses, and collaborating with field experts.

• Analyze policy coverage to determine the extent of liability and benefits payable to claimants.

• Evaluate the extent of loss or damage and determine the appropriate settlement amount.

• Communicate with claimants, policyholders, and other stakeholders to explain the claims process, request additional information, and provide status updates.

• Make recommendations for claims approval, denial, or negotiation of settlements, and ensure timely processing.

• Maintain accurate and organized claim files and records.

• Stay updated on industry regulations and maintain compliance with legal requirements.

• Provide excellent customer service, addressing inquiries and concerns from claimants and policyholders.

• Strive for high efficiency and accuracy in claims processing, minimizing errors and delays.

• Stay informed about industry trends, insurance products, and evolving claims management best practices.

• Generate and submit regular reports on claims processing status and trends.

• Perform other duties as assigned.

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Expected/Key Results

• XXXXX

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.

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Top of Form Education

• High School diploma or equivalent required

Work Experience

• Health claims processing experience [referred] [required ], including use of claims processing software and related tools

Competencies & Skills

• Highly-motivated and success-driven 

• Exceptional verbal and written communication and interpersonal skills, including negotiation and active-listening skills

• Exceptional analytical and problem-solving skills 

• Strong attention to detail with a commitment to accuracy

• Ability to adapt to change in a dynamic fast-paced environment with fluctuating workloads

• Basic mathematical skills

• Intermediate typing skills

• Basic computer skills 

• Knowledge of medical terminology, ICD-9/ICS-10, CPT, and HCPCS coding, and HIPAA regulations preferred

• Knowledge of insurance policies, regulations, and best practices preferred

Additional Qualifications

• Ability to download 2-factor authentication application(s) on personal device, in accordance with company and/or client requirements

• 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.

This position may work onsite or remotely from home.  

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Must be able to regularly or frequently talk and hear, sit for prolonged periods, use hands and fingers to type, and use close vision to view and read from a computer screen and/or electronic device.  Must be able to occasionally stand and walk, climb stairs, and lift equipment up to 25 pounds.

Firstsource is an Equal Employment Opportunity employer.  All employment decisions are based on valid job requirements, without regard to race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, age, disability, genetic information, veteran status, or any other characteristic protected under federal, state or local law.  

Firstsource also takes Affirmative Action to ensure that minority group individuals, females, protected veterans, and qualified disabled persons are introduced into our workforce and considered for employment and advancement opportunities.