Claims Examiner I

Job Summary Claims Examiner I reports to the Supervisor of Claims. The role involves reviewing and processing medical, dental, vision, and electronic claims in accordance with state, federal, and health plan regulations, and internal department guidelines. The examiner analyzes claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position also assists in resolving issues from providers, customer service, member services, and other internal stakeholders. Compensation $40,580.28 - $52,756.02 with a rich benefits package that includes profit‑sharing. Qualifications High school education or equivalent. Minimum 3–5 years of experience as a Health Claims Examiner or comparable industry experience preferred. At least 1 year of experience as a Claims Examiner for medical, dental, vision, subrogation, and accident claims. Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and benefit determination. Basic knowledge of medical terminology; familiarity with UB‑04, HCFA 1500, ICD‑10, CPT, and HCPCS codes. Good verbal and written communication skills. Proficiency in 10‑key data entry/type 40 WPM; Microsoft Office (Word, Excel, Outlook, PowerPoint) and quick learning of new applications. Ability to work under pressure and adapt to a changing environment. Working knowledge of the Employee Retirement Income Security Act (ERISA) claims processing/adjudication guidelines. Duties and Responsibilities Claims Processing & Quality Assurance Adjudicate all claim types—including dental, vision, medical, inpatient, outpatient, Blue Card, physician, in‑network and out‑of‑network, Medicaid reclamation, lab, radiology, accident, and third‑party liability—calculating benefit due and approving or denying based on SPD and within corporate cycle timeframe. Analyze patient and medical records to identify investigation needs for appropriate claim benefits, pricing, prior authorization or coordination of benefits. Verify claim files for accuracy (eligibility, authorization, etc.) and contact Health Care Providers for required documentation. Research through vendor portals such as Valenz, Occunet, Anthem. Resolve benefit and eligibility issues that require detailed knowledge and support customers within the claims processing framework. Process low‑ to medium‑level claim revisions and re‑pricing corrections. Respond to all correspondence and internal communication related to electronic and paper claims. Maintain a HIPAA‑compliant workstation and employ proper security techniques to protect confidential client and enrollee data. Meet and maintain individual and departmental productivity and quality standards. Problem Solving, Judgment & Compliance Examine problems, data, or text, consider multiple viewpoints, and weigh consequences before making decisions. Ensure compliance with all relevant policies, local, state, and federal regulations, and contract administration requirements. Partner with peers to document and analyze functional requirements, identify gaps, and propose alternative solutions. Contribute to defining, documenting, and periodically reviewing standards to integrate industry best practices. Alert supervisors to potential higher‑risk compliance issues. Make timely and effective decisions based on available information. Identify trends, research and determine actions to advance decision‑making within realistic timeframes and follow up as necessary. Involve relevant stakeholders in defining, understanding impacts, and resolving issues. Other Requirements Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds. Home router with wired Ethernet; wireless connections and hotspots are not permitted. A designated office space or steps taken to protect company information. A functioning smoke detector, fire extinguisher, and first aid kit on site. Maintain a HIPAA‑compliant workstation and use appropriate security techniques to protect confidential client data. All other duties as assigned. Physical Demands / Work Environment The role requires regular communication with others, frequent movement around the office, use of tools and equipment, and is performed in a moderate noise‑level environment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job successfully. #J-18808-Ljbffr Pinnacle Claims Management