Claims Examiner

Job Overview

The Claims Examiner is responsible for reviewing, analyzing, and processing healthcare insurance claims to ensure accuracy, completeness, and compliance with company policies and applicable regulations. This role works closely with providers, members, and internal departments to resolve claim discrepancies efficiently.

Duties

• Assures claims are input into 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/vision claims in accurate and timely manner as assigned.
• Review and interpret plan documents to appropriately apply plan benefits.
• Assist client service representatives answer phone calls and assist in 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.

Qualifications and Skills

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

Physical Requirements

ESSENTIAL TECHNICAL/MOTOR SKILL: Demonstration of prior work experience in the operation of standard office computer software. Prior data entry computer skills essential. Ability to understand the operation of the in-house computer system and how it relates to the operation of the business. Ability to use various office machines.

PEOPLE SKILLS: Excellent interpersonal and communication skills.

ESSENTIAL PHYSICAL REQUIREMENTS: Must be able to sit for extended periods of time. Must be able to move between offices within the department and to other departments throughout the building. Will include bending, twisting, and reaching. Must be able to kneel, reach, and lift heavy objects (30 lbs.)

ESSENTIAL MENTAL ABILITIES: Able to work independently, managing multiple tasks, analyzing, and assessing while following established policies and procedures and making decisions on the steps to take. Must be able to work in a fast-paced, high pressured work environment. May require over-time hours.

TRAVEL: Some travel may be required.

EXPOSURE TO HAZARDS: None.

RCI Group II, LLC, is an equal opportunity employer and is committed to creating an inclusive workplace.

Pay: $33,051.00 - $55,000.00 per year

Benefits:

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

Work Location: In person

Salary : $33,051 - $55,000