Claims Examiner II

Position Summary

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, institutional, professional, dental, and adjustments to claims. This position may also have a Quality Assurance component.

Work Location

This position has the option to work remotely.

Responsibilities

• 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 online tools.
• Consistently maintain 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 COB, Action Requests, Correspondence, Receipts, Audit and Quality (AQ) work items and claim adjustments.
• Provide accurate information regarding benefits, providers, claims, referrals, eligibility, pharmacy, etc.
• 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 current claims processing experience.
• CPT, ICD-10, & HCPCS proficiency.

Benefits

• 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.

Physical Requirements

• Ability to see and hear at normal levels with or without aid.
• Ability to sit for long periods of time.
• Finger and hand dexterity.
• Ability to bend and twist.