[Hiring] Claims Examiner II @HealthEdge

Role Description

The Claims Examiner II is responsible for the adjudication of healthcare claims utilizing specific policies and procedures. This role is responsible for reviewing data within the claims processing system to determine if services rendered were appropriate and benefit coverage criteria were met. The Claims Examiner II is accountable for reviewing the adjudication system edits to determine whether to pay the claim and/or line item(s).

• Process assigned claims based on client-specified guidelines or as directed by the team leader.
• Meet productivity targets, financial and procedural accuracy standards as established by management.
• Mentor junior members of the team.
• Collaborate with other team members on special projects as assigned by the team leads; special projects can include:
  • Process documentation development
  • Training
  • Quality audits
  • Assisting with surge activity for the client(s)
  • Any other project as determined by the team leader
• Maintain knowledge base around physician practices and hospital coding, billing and medical terminology, CPT, HCPCS, and ICD-10, UB04, CMS 1500, authorizations, medical terminology, and concepts of healthcare.
• Establish and maintain an appropriate level of communication with management to address issues and concerns and take preventive measures that ensure processing accuracy and quality.
• Participate in projects assigned by the team leader; these projects may include provider data, authorizations, enrollment, or other activities.

Qualifications

• High School degree required
• 1 – 3 years healthcare claims processing experience
• Solid understanding and ability to analyze claim data
• ICD-10, CPT, and HCPCS coding knowledge is a plus
• Willingness to learn new skills
• Team collaborator
• Strong work ethic

Requirements

• The ability to adapt quickly to a fast-paced environment
• A self-starter and quick learner
• Team player with an ability to collaborate

Benefits

• Remote work opportunity
• Full-time, permanent employment
• Annual US hourly range for this position is $17.00 to $19.00/hr
• Final compensation will be determined during the interview process based on skills, experience, qualifications, and education

Company Description

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology.

UST HealthProof is run by leaders with strong health plan and technology backgrounds who have start-up mindsets and an environment of support where individual growth is nurtured. You will be supporting our proven core admin solutions and business process-as-a-service (BPaaS) operations to provide transparency, improve operational efficiency, and break down operational barriers to scale and drive strategic growth.