Claims Examiner II
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Job Description
Claims Examiner II adjudicating healthcare claims for HealthEdge’s health insurance technology platform. Reviewing coding, coverage criteria, and system edits while mentoring team members.
Responsibilities:
- Process assigned healthcare claims based on client-specified guidelines or team-leader direction
- Meet productivity targets and financial and procedural accuracy standards established by management
- Review claims-processing-system data to determine whether services were appropriate and benefit coverage criteria were met
- Review adjudication-system edits to determine whether to pay claims and/or line items
- Mentor junior team members
- Collaborate on special projects, including process documentation, training, quality audits, and surge activity
- Communicate with management about issues and concerns and take preventive measures to ensure processing accuracy and quality
- Participate in projects involving provider data, authorizations, enrollment, or other assigned activities
- Report to the Claims Team Leader
Requirements:
- High School degree required
- 1–3 years healthcare claims processing experience
- Solid understanding and ability to analyse claim data
- Knowledge of physician practices and hospital coding, billing, and medical terminology
- Knowledge of CPT, HCPCS, ICD-10, UB04, CMS 1500, authorizations, and healthcare concepts
- ICD-10, CPT, and HCPCS coding is a plus
- Willingness to learn new skills
- Team collaborator
- Strong work ethic
- Ability to adapt quickly to a fast-paced environment
- Self-starter and quick learner
- Ability to collaborate
- Candidates may be required to complete a pre-employment criminal background check
Benefits:
- Remote work environment
- May require travel dependent on company needs
- Reasonable accommodations for individuals with disabilities
- Equal opportunity employer committed to workforce diversity
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