Claims Examiner Medical

Job Overview The claims examiner is a detail-oriented and organized individual. This role is responsible for efficiently and accurately processing insurance claims while ensuring compliance with company policies and regulatory requirements. The Claims Processor is also responsible for communicating with their client, management, and other teams within the organization. Responsibilities Claims Processing: Review and evaluate medical, dental, DME and other insurance claims for accuracy, completeness, and eligibility according to established guidelines. Documentation: Maintain comprehensive and organized records of all claims processed, including relevant correspondence, documentation, and payment information. Verification: Verify participant information, authorization details, and contractual limits to determine the validity of claims and assess liability. Communication: Correspond with clients, providers, vendors, other teams, and other relevant parties to gather necessary information, clarify details, and provide updates on claim status. Adjudication: Analyze claim documents and supporting evidence to determine claim outcomes and make decisions regarding reimbursement. Investigation: Conduct investigations as necessary to resolve discrepancies, identify potential fraudulent activity, and mitigate risks to the company. Compliance: Ensure compliance with company policies, industry regulations, and legal requirements throughout the claims processing workflow. Reporting: Generate reports and statistics on claim processing activities, trends, and outcomes to support management decision-making and performance evaluation. Customer Service: Provide courteous and professional assistance to clients and providers, addressing inquiries, concerns, and complaints in a timely and effective manner. Continuous Improvement: Identify opportunities for process improvement, efficiency gains, and enhanced customer satisfaction within the claims processing function. Miscellaneous: Assist with projects, reporting, and other duties as requested by management. Qualifications High school diploma or equivalent. Proven experience in claims processing, insurance administration, or a similar role within the insurance industry. Strong understanding of Program of All Inclusive Care for the Elderly (PACE), coverage terms, and claims procedures. Excellent analytical skills with the ability to assess complex information and make sound decisions. Exceptional attention to detail and accuracy in data entry and record-keeping. Proficient computer skills, including experience with claim processing software and Microsoft Office applications. Effective communication skills, both written and verbal, with the ability to interact professionally with diverse stakeholders. Ability to prioritize tasks, manage workload efficiently, and meet deadlines in a fast-paced environment. Knowledge of regulatory requirements and compliance standards relevant to insurance claims processing is a plus. Expected hours: 40 per week Benefits: Health insurance Paid time off Application Question(s): Do you have knowledge and experience with PACE programs Do you have at least 5 years of medical claims experience Work Location: Remote Apply To this Job Company : innermark TPA Salary : Full-time .