Claims Examiner I [United States]

 

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include:

• Competitive benefits package with day one eligibility
• Employer covers 90% of monthly premium cost for health, dental and vision plans
• Annual employee bonus program to reward success

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  Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities and tuition reimbursement program
• Robust 401(k) with 50% match and end of year discretionary employer contribution
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

Job Description Summary:

Under general supervision, assesses claim information, references contracts and performs calculations and other functions to accomplish the processing and payment of insurance claims of a complicated or non-routine nature. Interprets contract information and communicates with outside parties to obtain information and coordinate coverage. Performs claim research and adjustments.

Job Description

EACH DUTY AND RESPONSIBILITY MUST BE PERFORMED IN ACCORDANCE WITH INDIVIDUAL PERFORMANCE SCORECARD PRODUCTION AND QUALITY STANDARDS.

• Successfully completes all training programs as required for the level.
• Processes claims for two products or claim types (dental, hospital, medical, ITS, FEP).
• Performs research and adjustment functions for claims.
• Perform special projects (e.g., complex accumulator reconsiderations, New Directions).
• Responds to written inquiries from internal and external customers as business needs dictate.
• Sets up deducts, CLOV table entries, and other assigned finance functions.
• For FEP positions, processes all deferrals for FEP or edit corrections in computerized claims system.
• Performs complex FEP transactions (e.g., FEP Direct DDE, FEP Retro-enrollment, Out of Balance) and member appeals.

Minimum Qualifications

• High school diploma or general education degree (GED).
• 2 years of previous customer service, member services, or claims processing experience; or any combination of required education and experience.
• Advanced Keyboarding Knowledge
• Intermediate knowledge of Microsoft Office

Preferred Qualifications

• Knowledge of FACETS and/or other computerized claims processing system as applicable (FEP).
• Associates degree from college or technical school

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