Job Brief
As a Health Claims Examiner, you will play a crucial role in reviewing and processing health insurance claims to ensure compliance with company policies and industry regulations. This position requires a keen eye for detail, analytical skills, and the ability to communicate effectively with various stakeholders, including legal counsel for complex claims requiring litigation. The ideal candidate will possess experience in claims processing, a strong understanding of healthcare regulations, and excellent problem-solving abilities.
Responsibilities
- Review settled health claims to ensure payments and settlements comply with company practices and procedures.
- Analyze claims data and documentation for accuracy and completeness.
- Confer with legal counsel on claims that require litigation or special handling.
- Investigate discrepancies in claims and coordinate with healthcare providers as necessary.
- Resolve claims disputes and negotiate settlements when applicable.
- Maintain detailed records of claims activity and prepare reports for management review.
- Stay updated on industry regulations, policy changes, and best practices in health claims processing.
- Collaborate with cross-functional teams to enhance claims processing efficiency and accuracy.
Requirements
- Bachelor’s degree in healthcare administration, business administration, or a related field.
- Minimum of 2 years of experience in health claims processing or a related area.
- Strong knowledge of healthcare regulations, coding systems, and insurance policies.
- Proficient in claims management software and Microsoft Office Suite.
- Excellent analytical and problem-solving skills.
- Strong attention to detail and ability to work independently.
- Effective communication skills, both verbal and written.
- Certifications such as Certified Medical Reimbursement Specialist (CMRS) or Certified Professional Coder (CPC) are a plus.
Similar Job Titles
- Claims Adjuster
- Insurance Claims Specialist
- Health Insurance Claims Analyst
- Claims Processing Specialist
- Claims Management Coordinator
- Medical Claims Examiner
- Health Claims Investigator
- Insurance Claims Administrator
