Claims Examiner
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Job Description
Claims Examiner at Point C processing medical claims and ensuring compliance with industry regulations. Requires attention to detail and experience in TPA or self-funded environments.
Responsibilities:
- Adjudicate new claims and process adjustments, including denials upon receipt of additional information
- Review and resolve appeals and subrogation/third-party liability cases
- Manage individual inventory to ensure timely turnaround and production goals are met
- Ensure claims are processed in accordance with stop loss contract terms
- Respond to internal and external inquiries via email and other channels within established timeframes
- Follow up on missing or incomplete information to ensure claims can be accurately processed
- Maintain minimum production, financial, and procedural accuracy standards on a monthly basis
Requirements:
- Associate's degree preferred
- Experience with Third Party Administrator (TPA) or self-funded claims administration preferred
- At least 1+ year of experience in insurance claims processing
- Working knowledge of CPT and ICD-10 coding
- Basic understanding of medical terminology
- Proficiency in Microsoft Office and general computer applications
- Strong communication and customer service skills
- Ability to maintain confidentiality and comply with all company policies and procedures
- Able to work independently with minimal supervision
- Ability to prioritize, multitask, and work overtime as needed
Benefits:
- Comprehensive medical, dental, vision, and life insurance coverage
- 401(k) retirement plan with employer match
- Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
- Paid time off (PTO) and disability leave
- Employee Assistance Program (EAP)
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