Claims Examiner Jobs

Health Special Risk, Inc. is seeking to add three experienced Claims Examiners to our growing team in Plano, Texas. The selected candidates will manage an assigned inventory consisting of K12 and Special Risk Accident Medical expense claims. This includes claims processing and adjudication, as well as investigation when required.

WHAT YOU WILL DO:

• Process and adjudicate payable claims according to established procedures and within authorized payment limits or determine the basis for denial of benefits.
• Achieve production-driven goals while maintaining highest level of quality.
• Ensure that all claims are handled in a timely manner to meet state-mandated requirements.
• Timely follow up on all suspends and referrals.
• Review claim with related documentation to determine if a claim is payable within policy provisions and limitations. Request additional information when needed.
• Identify and route claims for repricing or negotiation according to processing guidelines.
• Perform other duties as assigned.

WHAT YOU WILL NEED:

• Knowledge of CPT, HCPC ICD-10 codes required.
• High school diploma or GED required; college courses in related field is a plus.
• Must possess the ability to learn quickly.
• Ability to make appropriate and sound decisions based on information provided.
• High level of motivation, strong work ethic, and be a supportive team player.
• Knowledge of HIPPA, pre-existing conditions, and coordination of benefits required.
• Insurance knowledge/experience with medical terms and billing is a plus.
• Excellent verbal and written communication skills.
• In-depth knowledge and ability to read and interpret medical policies to determine claim eligibility.
• Ability to work independently under limited supervision.
• Strong detail-oriented and analytical skills.
• Minimum of 3 years of previous claims processing/adjudication experience. Trizetto QicLink or RIMS experience is a plus.
• Proficiency with MS Office Suite.

This job description is not meant to be an all-inclusive statement of the duties of the position listed above. Other appropriate duties may be required from time to time.

WHAT WE OFFER:

• A chance to work for a smaller Third-Party Administrator (TPA) business and be recognized, while enjoying the stability and benefits of an S&P 500 company as a member company of Brown & Brown, Inc.!
• Paid Time Off including Holiday Pay
• Employee Stock Purchase Plan
• This is a fully-remote position. If selected candidate is local, training period will take place on-site until acclimated in role and then convert to fully-remote work status.
• Generous benefits package: Health, Dental, Vision, 401(k), etc.
• Competitive pay based on experience

We are an Equal Opportunity Employer. We take pride in the diversity of our team and seek diversity in our applicants.