Claims Examiner

3 weeks ago


San Antonio TX, United States HealthTexas Full time

The Claims Examiner & Support Specialist Level I is responsible for accurately processing health plan delegated claims, addressing provider inquiries via phone calls, and handling various administrative tasks within the department. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission “to deliver quality and compassionate care with outstanding service, every patient, every time”. Processing Health Plan Delegated Claims:
Reviewing claim submissions for accuracy and completeness.
Verifying information provided in claims to ensure it aligns with established guidelines.
Adjudicating claims according to the policies and regulatory guidelines set by the health plans.
Ensuring the accurate and timely processing of delegated claims.
Answering Phone Calls:
Handling incoming phone calls from healthcare providers and other stakeholders.
Providing prompt and accurate responses to inquiries related to claims processing.
Documenting phone calls to include topics discussed and resolution.
Addressing concerns and questions from providers regarding claims.
Assisting with claim-related issues and resolving problems over the phone.
Administrative Functions:
Performing various administrative tasks to support the efficient operation of the claims processing department.
Conducting data entry accurately and efficiently.
Processing incoming mail related to claims and ensuring timely distribution.
Handling other clerical duties as assigned by supervisors or managers.
Being flexible and willing to take on additional responsibilities as needed.
Adapting to changes in workflow or procedures within the claims processing department.
To excel in this role, attention to detail, knowledge of healthcare claim processing, and effective communication skills are crucial. You must be familiar with the specific guidelines and policies of the health plans you are working with and stay updated on any changes. 1 year of call center experience preferred
~6 months claims adjudication experience preferred
~1 year experience in Claims department is a plus

Basic knowledge of healthcare terminology, coding, and claim processing procedures.
Strong attention to detail and accuracy in data entry.
Familiarity with relevant software and computer skills for data entry and claims processing systems, a plus.
Basic knowledge of Microsoft Office including Outlook, Word, Excel, and Teams.
Data Entry/Typing skills, a minimum of 50 words per minute.
Work Hours, Travel Requirements
Monday – Friday, 8:00 a.m. – and as needed to complete projects.
Travel to medical offices may be necessary for the purpose of providing benefit education.
This job operates in an office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, scanners, filing cabinets and fax machines.

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