Health Claims Examiner

Job Summary

Reviewing and evaluating health insurance claims, the remote Health Claims Examiner I will ensure timely and accurate adjudication of claims while maintaining compliance with company policies and state regulations.

Key responsibilities

• Analyze claim documentation to determine eligibility for payment in accordance with policy provisions and regulations
• Correspond with policyholders and other parties regarding claim requirements and status, while processing routine claims within established authority limits
• Document all claim activities and escalate complex or suspicious claims to management for further review

Required qualifications

• Bachelor's degree or 2-5 years of related experience and/or training, or equivalent combination of education and experience
• At least 1 year of experience in a claims support role, preferably in health insurance or healthcare operations
• Progress toward or completion of insurance industry coursework or designations (e.g., FLMI, ALHC, ACS)
• Basic understanding of health insurance products, claim payment processes, and state insurance regulations
• Knowledge of HIPAA and compliance requirements related to health claims