[Hiring] Claims Examiner @Addison Group

Role Description

The Claims Examiner will be responsible for reviewing, evaluating, and processing healthcare-related insurance claims. This position requires a strong understanding of claims procedures, benefit information, documentation requirements, and applicable regulations. The ideal candidate is detail-oriented, analytical, organized, and able to communicate effectively with both internal and external stakeholders.

• Review submitted claims to verify eligibility, required documentation, accuracy, and applicable coverage.
• Evaluate claims using plan provisions, established procedures, and applicable benefit guidelines.
• Determine appropriate claim outcomes, including approvals, adjustments, payment calculations, or denial determinations.
• Prepare or coordinate claim-related correspondence when additional information or a denial explanation is required.
• Follow applicable federal and state regulations, privacy requirements, and internal claims procedures.
• Maintain complete and accurate records of claims, payments, adjustments, denials, and supporting documentation.
• Respond to questions from healthcare providers, clients, and internal teams regarding claim status and processing decisions.
• Identify potential payment discrepancies, including overpayments and underpayments, and escalate issues appropriately.
• Communicate with external partners and other stakeholders to obtain information necessary to complete claim reviews.
• Confirm member eligibility, benefit levels, authorizations, and coverage details as needed.
• Recognize missing or inconsistent documentation and work with the appropriate parties to resolve outstanding issues.
• Protect confidential information and follow HIPAA and other applicable privacy standards.
• Utilize claims systems, computer applications, and emerging technology tools to improve accuracy, efficiency, and service.
• Contribute to departmental projects, process improvements, and other duties as assigned.

Qualifications

• High school diploma or equivalent required.
• At least 1 year of experience in healthcare claims processing, reimbursement, or a related field.
• Ability to interpret written policies, benefit information, procedural guidelines, and government regulations.
• Proficiency with standard computer applications, including email, spreadsheets, word processing, and database systems.
• Strong attention to detail and the ability to analyze information and identify discrepancies.
• Effective problem-solving and decision-making skills.
• Strong written and verbal communication abilities.
• Ability to manage multiple priorities and adjust to changing workloads.
• Ability to work effectively with internal teams, providers, clients, and other business partners.

Requirements

• This position requires a high level of accuracy and discretion when handling sensitive claims and member information.
• Candidates should be comfortable working independently while also collaborating with a broader team.
• The responsibilities listed above are representative of the position and may be modified based on business needs.

Benefits

• Competitive compensation.
• Medical, dental, and vision benefits.
• 401(k) retirement savings opportunity.
• Paid time off and company holidays.
• Employee assistance and wellness resources.
• Professional development and career growth opportunities.
• Collaborative and supportive work environment.