Medical Claims Examiner

3 days ago

Aurora, Colorado, United States UNITE HERE HEALTH Full time
Job Title: Claims Adjudicator I

UNITE HERE HEALTH is a leading healthcare provider serving 190,000+ workers and their families nationwide. We strive to innovate and progress, developing impactful programs and benefits to engage participants in managing their health and healthcare.

The Claims Adjudicator I position is a fully remote opportunity. As an Adjudicator, you will receive, examine, verify, and input submitted claim data, determine eligibility status, and review and adjudicate claims within established timeframes.

This role utilizes multiple systems to perform day-to-day functions of processing medical, disability, vision, and dental claims, as well as provider and member-driven inquiries.

Essential Job Functions and Duties
  • Screen claims for completeness of necessary information
  • Verify participant/dependent eligibility
  • Interpret plan benefits from the Summary Plan Description (SPD)/Plan Documents
  • Code basic information and select codes to determine payment liability amount
  • Evaluate diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
  • Determine the need for additional information or documentation from participants, employers, providers, and other insurance carriers
  • Adjudicate claims according to established productivity and quality goals
  • Request overpayment refunds, maintain corresponding files, and perform follow-up actions
  • Handle verbal and written inquiries received from internal and external customers
  • Achieve individual established goals to meet or exceed departmental metrics
Essential Qualifications
  • 2-3 years of related experience in a medical claim adjudication environment
  • Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
  • Experience with eligibility verification, medical coding, coordination of benefits, and subrogation
  • Experience with medical terminology, International Classification of Diseases (ICD)10, and Current Procedures Terminology (CPT) codes
Hourly Range

$22.62 an hour. Actual hourly rate may vary based on relevant experience, qualifications, expertise, certifications, licenses, education, or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule: Monday-Friday, 7.5 hours per day (37.5 hours per week) as a full-time remote position.

We offer great benefits, including medical, dental, vision, paid time-off (PTO), paid holidays, 401(k), pension, short- and long-term disability, life, AD&D, flexible spending accounts (healthcare & dependent care), commuter transit, tuition assistance, and employee assistance program (EAP).

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