Claims Examiner
$35,360–$41,600 year
RemoteUnited States
United StatesRemoteFull Time$35,360–$41,600 yearLarge
Full TimeLarge
Job Summary
Review, validate, and process medical, behavioral health, and pharmacy claims while researching discrepancies, eligibility concerns, and authorization requirements. Analyze suspended, denied, or rejected claims to determine next steps and coordinate appeals and grievances with internal clinical, compliance, and provider services teams. Document all actions within the claims management system, maintain Protected Health Information confidentiality, and participate in quality audits and continuous improvement initiatives. Ensure accurate documentation, meet regulatory turnaround times, and contribute to process reviews.
Required Qualifications
- High School Diploma or GED
- Associate's or Bachelor's degree
- Minimum of 2 years of experience in US Healthcare Back Office Operations
- Experience in healthcare claims processing and Appeals & Grievances
- Knowledge of commercial, Medicare, and/or Medicaid health plans
- Understanding of medical terminology, healthcare benefits, and claim workflows
- Familiarity with CPT, ICD-10-CM, HCPCS, and healthcare documentation
- Experience working with claims processing systems, workflow management tools, and electronic document management systems
- Proficiency with Microsoft Office, including Excel, Word, and Outlook
- Strong written and verbal communication skills
- Excellent analytical, organizational, and problem-solving abilities
Desired Qualifications
- Experience in Managed Care, Health Insurance, Third-Party Administration (TPA), or Healthcare Business Process Outsourcing (BPO)
- Knowledge of healthcare regulations governing appeals and grievance processes
- Experience handling high-volume production environments
- Familiarity with quality assurance processes and operational audits
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