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

Experience with Third Party Administrator (TPA) or self-funded claims administration preferred
At least 2+ years of experience in insurance claims processing required
Experience reviewing and finalizing claim payments for accuracy in accordance with plan policies
Ability to interpret and apply plan documents to ensure accurate claims adjudication
Demonstrated understanding of both claim review processes and underlying benefit plan design
Experience with HealthPac, El Dorado, Javelina, or VBA systems preferred
Working knowledge of CPT and ICD-10 coding
Basic understanding of medical terminology
Strong communication and customer service skills
Proficiency in Microsoft Office and general computer applications
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
Associate Degree Preferred

Claims Examiner

Key skills