Claims Examiner

firstsourc · United States

Job Title: Claims Examiner Job Type: Full Time FLSA Status: Non-Exempt/Hourly Grade: H Function/Department: Health Plan and Healthcare Services Reporting to: Team Lead/Supervisor - Operations Pay Rate: $17/hr Role Description: The Claims Examiner evaluates insurance claims to determine whether their validity and how much compensation should be paid to the policyholder. The Claims Examiner is responsible for reviewing all aspects of the claim, including reviewing policy coverage, damages, and supporting documentation provided by the policyholder. 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.
• Perform other duties as assigned.

• Highly-motivated and success-driven
• Exceptional verbal and written communication and interpersonal skills, including negotiation and active-listening skills
• Exceptional analytical and problem-solving skills
• Strong attention to detail with a commitment to accuracy
• Ability to adapt to change in a dynamic fast-paced environment with fluctuating workloads
• Basic mathematical skills
• Intermediate typing skills
• Basic computer skills
• Knowledge of medical terminology, ICD-9/ICS-10, CPT, and HCPCS coding, and HIPAA regulations preferred
• Knowledge of insurance policies, regulations, and best practices preferred

• Ability to download 2-factor authentication application(s) on personal device, in accordance with company and/or client requirements
• Ability to pass the required pre-employment background investigation, including but not limited to, criminal history, work authorization verification and drug test