Claims Examiner

About This Role

The Claims Examiner reviews, analyzes, and processes healthcare insurance claims, ensuring accuracy, completeness, and compliance with company policies and regulations. This role involves close collaboration with providers, members, and internal departments to efficiently resolve claim discrepancies.

Responsibilities

• Assure claims are input into the system with appropriate screening criteria such as membership, providers, codes, dates of service, charges, and PPO network repricing if appropriate
• Adjudicate and follow up with health, dental, and vision claims in an accurate and timely manner as assigned
• Review and interpret plan documents to appropriately apply plan benefits
• Assist client service representatives in answering phone calls and reviewing claims on phone calls if needed
• Meet productivity and accuracy performance standards
• Ensure compliance with HIPAA and industry regulations
• Verify patient eligibility and coverage details
• Perform day-to-day workflow as directed, including any special projects and requests
• Maintain detailed documentation of claim decisions
• Investigate and resolve denied, pending, or rejected claims
• Perform other work as may be required

Requirements

• High school diploma or GED
• 1-2 years of claims processing or healthcare billing experience required
• Knowledge of Medical Terminology, CPT, ICD-10, and HCPCS coding
• Familiarity with healthcare insurance policies and claims systems
• Strong analytical and problem-solving skills
• High attention to detail and accuracy

Nice to have:

• Knowledge of Third-Party Administrator services

Benefits

• 401(k)
• Dental insurance
• Health insurance
• Health savings account
• Paid time off
• Vision insurance

Important Details

• Travel: Some travel may be required

About the Company

RCI Group II, LLC, is committed to creating an inclusive workplace.