Claims Examiner

We are looking for a Claims Examiner, someone who’s ready to grow with our company. In this position, you will process and adjudicate claims received for reimbursement to Providers based on extensive review, research, and a detailed format of claim processing procedures. 


Think you’ve got what it takes? 

Job Duties & Responsibilities 
•    Adjudicate claims received into processing system. 
•    Thoroughly reviews, investigates, and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time. 
•    Examiners should process at least 14 claims per hour, or 98 claims per day. 
•    Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days. 
•    Macess requests are processed within 30 days of receipt, with a 98% accuracy, to ensure timely resolution of claims, in adherence with HHSC regulatory requirements. 
•    The claims are processed accurately as defined by standard guidelines. 
•    The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports. 
•    The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review. 
•    The claims that are manually adjudicated must have notes entered as reviewed by weekly audits, check run, returned claims, management review 98% of the time. 
•    Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication. 
•    Complete special projects as requested. 
Skills & Requirements 
•    Required H.S. Diploma or GED 
•    Required 1 year claims examination experience