Remote Claims Examiner

Location: Remote, US

Description:

Job Title: Claims Examiner

Job Type: Full Time

Grade: H

Function/Department: Health Plan and Healthcare Services

Reporting to: Team Leader -Operations

Pay Rate: $17/hr

Role Description: We are seeking a highly-motivated and success-driven Insurance Claims Representative who combines exceptional analytical and problem-solving skills, with the ability to positively adapt to change in a dynamic fast-paced environment. It is also vital that you display exceptional verbal and written communication, negotiation and active-listening skills, as well as the ability to work effectively in an environment with fluctuating workloads.

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

referred Educational Qualifications

• High School diploma or GED

Preferred Work Experience

• Health claims processing experience a plus

Competencies & Skills

• Knowledge in the following a plus:

• medical terminology

• ICD-9/ICS-10, CPT, and HCPCS coding

• HIPAA regulations

• PC applications and systems

• Ability to read and interpret general business correspondence, procedure manuals, and specific plan documents

• Basic mathematical skills

• Intermediate typing skills

• Multiple computer application usage experience

• Strong analytical and problem-solving skills.

• Excellent communication and interpersonal skills.

• Proficient in using claims processing software and related tools.

• Detail-oriented with a commitment to accuracy.

• Knowledge of insurance policies, regulations, and best practices