6 Health Claims Examiner Job Description Templates and Examples

Company Overview

[$COMPANY_OVERVIEW]

Role Overview

We are looking for a detail-oriented Junior Health Claims Examiner to join our dedicated team at [$COMPANY_NAME]. In this role, you will play a crucial part in reviewing and processing health insurance claims, ensuring accuracy and compliance with relevant policies and regulations. This entry-level position offers an excellent opportunity for growth and development within the health insurance industry.

Responsibilities

• Review health insurance claims for completeness and accuracy, verifying that all necessary documentation is provided.
• Evaluate claims against policy guidelines and regulations to determine eligibility and appropriate payment amounts.
• Communicate with healthcare providers and policyholders to resolve discrepancies and gather additional information as needed.
• Maintain up-to-date knowledge of industry standards, regulations, and company policies to ensure compliance.
• Assist in identifying trends in claim submissions and processing issues to support continuous improvement initiatives.
• Collaborate with senior examiners and other team members to enhance departmental efficiency and service quality.

Required Qualifications

• Associate degree or equivalent experience in healthcare, insurance, or a related field.
• Strong attention to detail and analytical skills.
• Basic understanding of health insurance concepts and claims processing.
• Excellent verbal and written communication skills.
• Proficiency in using standard office software and claims management systems.

Preferred Qualifications

• Experience in a healthcare or insurance setting is a plus.
• Knowledge of medical terminology and coding is beneficial.
• Desire to pursue further education or certification in health insurance or claims examination.

Soft Skills and Cultural Fit

• Demonstrated ability to work collaboratively as part of a team.
• Strong organizational skills with the ability to manage multiple tasks and deadlines effectively.
• A proactive attitude towards problem-solving and continuous learning.
• Commitment to delivering quality service to internal and external stakeholders.

Benefits and Perks

We offer a competitive salary and benefits package, which includes:

• Health, dental, and vision insurance
• Retirement savings plan with company match
• Generous paid time off policy
• Professional development opportunities

Equal Opportunity Statement

[$COMPANY_NAME] is committed to diversity in its workforce and is proud to be an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, creed, gender, national origin, age, disability, veteran status, sex, gender expression or identity, sexual orientation or any other basis protected by applicable law.

Location

This role requires successful candidates to be based in-person at our office located in [$COMPANY_LOCATION].

We encourage applicants from diverse backgrounds and experiences to apply, even if they do not meet all listed qualifications.

Company Overview

[$COMPANY_OVERVIEW]

Role Overview

We are seeking a meticulous and detail-oriented Health Claims Examiner to join our team at [$COMPANY_NAME]. In this role, you will be responsible for evaluating and processing health insurance claims, ensuring accuracy and compliance with industry regulations. Your expertise will play a critical role in maintaining the integrity of our claims processing system and enhancing the customer experience.

Responsibilities

• Review and analyze health insurance claims for accuracy, completeness, and compliance with state and federal regulations
• Determine medical necessity and appropriateness of services based on established guidelines and policies
• Communicate with healthcare providers, patients, and internal departments to resolve discrepancies and gather additional information as needed
• Utilize claims processing software and tools to document findings and maintain accurate records
• Assist in the development and implementation of policies and procedures to improve claims processing efficiency
• Participate in training and mentoring of new staff members to foster a culture of continuous improvement

Required and Preferred Qualifications

Required:

• 1+ years of experience in health claims processing or a related field
• Strong understanding of medical terminology, coding, and billing practices
• Proficient in using claims management software and Microsoft Office Suite
• Excellent analytical and problem-solving skills with a keen attention to detail

Preferred:

• Associate's or Bachelor's degree in healthcare administration, business, or a related field
• Certification in health claims examination or related professional credential
• Experience with electronic health records (EHR) systems and data analysis tools

Technical Skills and Relevant Technologies

• Proficiency in claims processing software (e.g., Facets, QNXT)
• Knowledge of CPT, ICD-10, and HCPCS coding systems
• Familiarity with healthcare regulations, including HIPAA compliance

Soft Skills and Cultural Fit

• Strong verbal and written communication skills
• Ability to work collaboratively in a remote team environment
• Demonstrated commitment to delivering exceptional customer service and resolving issues effectively
• Adaptable and open to feedback, with a continuous improvement mindset

Benefits and Perks

Competitive salary commensurate with experience, plus additional benefits including:

• Comprehensive health, dental, and vision insurance
• 401(k) plan with company matching
• Paid time off and holidays
• Professional development and training opportunities

Equal Opportunity Statement

[$COMPANY_NAME] is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status.

Location

This is a remote position within [$COMPANY_LOCATION].

Company Overview

[$COMPANY_OVERVIEW]

Role Overview

We are seeking a detail-oriented and experienced Senior Health Claims Examiner to join the claims processing team at [$COMPANY_NAME]. In this critical role, you will leverage your extensive knowledge of health insurance policies and regulations to evaluate and adjudicate complex health claims, ensuring compliance with industry standards and organizational guidelines.

Responsibilities

• Review and analyze complex health insurance claims, verifying accuracy, completeness, and adherence to policy provisions.
• Utilize advanced analytical skills to identify discrepancies, trends, and potential fraud within claims submissions.
• Collaborate with healthcare providers, policyholders, and internal teams to resolve claims issues and ensure timely processing.
• Provide mentorship and guidance to junior claims examiners, fostering a culture of continuous improvement and operational excellence.
• Stay current on industry trends, regulatory changes, and best practices to drive process enhancements and mitigate risk.
• Prepare detailed reports and documentation related to claims processing and outcomes for internal stakeholders.

Required and Preferred Qualifications

Required:

• 5+ years of experience in health claims examination or a related field, with a strong understanding of medical terminology and coding.
• In-depth knowledge of healthcare regulations, including HIPAA and other compliance requirements.
• Proficiency in claims management systems and related software tools.
• Strong attention to detail and ability to analyze complex information effectively.

Preferred:

• Bachelor's degree in healthcare administration, business, or a related field.
• Certified Professional Coder (CPC) or equivalent certification.
• Experience working with electronic medical records (EMR) systems.

Technical Skills and Relevant Technologies

• Expertise in medical coding systems (ICD-10, CPT, HCPCS) and regulatory guidelines.
• Proficient in data analysis tools and claims management software.
• Familiarity with electronic claims submission and processing platforms.

Soft Skills and Cultural Fit

• Exceptional interpersonal and communication skills, capable of engaging effectively with diverse stakeholders.
• Strong problem-solving skills with a strategic mindset for tackling complex claims challenges.
• Ability to work collaboratively within a team environment while maintaining a high level of independence.
• Commitment to maintaining confidentiality and ethical standards in claims processing.

Benefits and Perks

Salary range: [$SALARY_RANGE]

Additional benefits may include:

• Comprehensive health insurance packages including medical, dental, and vision coverage.
• Retirement savings plans with company matching contributions.
• Generous paid time off (PTO) and holiday schedule.
• Opportunities for professional development and continuing education.
• Employee wellness programs and resources.

Equal Opportunity Statement

[$COMPANY_NAME] is committed to diversity and inclusion within our workforce. We encourage applications from all qualified individuals regardless of race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status. We strive to create a diverse and inclusive workplace where everyone feels valued and empowered.

Location

This role requires successful candidates to be based in-person at our office located in [$COMPANY_LOCATION].

Company Overview

[$COMPANY_OVERVIEW]

Role Overview

We are seeking a strategic and detail-oriented Lead Health Claims Examiner to join our dynamic team at [$COMPANY_NAME]. In this pivotal role, you will oversee the examination and adjudication of health claims, ensuring compliance with industry regulations and internal policies, while providing mentorship and guidance to junior examiners. Your expertise will play a crucial role in enhancing the accuracy and efficiency of our claims processing system.

Responsibilities

• Lead the claims examination process, ensuring accurate and timely adjudication of health claims according to established guidelines and regulatory standards.
• Mentor and train junior claims examiners, fostering a culture of continuous learning and improvement within the team.
• Collaborate with cross-functional teams, including underwriting, legal, and compliance, to resolve complex claims issues and enhance operational efficiencies.
• Analyze claims data to identify trends, discrepancies, and opportunities for process improvement.
• Develop and implement best practices for claims processing, ensuring adherence to quality standards and regulatory requirements.
• Prepare detailed reports and presentations for senior management, highlighting key performance metrics and areas for improvement.
• Stay abreast of industry trends, regulations, and technological advancements to ensure the claims processing team remains competitive and compliant.

Required and Preferred Qualifications

Required:

• 5+ years of experience in health claims examination or a related field, with a proven track record of success.
• Strong knowledge of health insurance regulations and claims processing procedures.
• Demonstrated leadership skills with the ability to mentor and develop junior team members.
• Exceptional analytical skills, with the capability to interpret complex data and make informed decisions.

Preferred:

• Bachelor's degree in healthcare administration, business, or a related field.
• Experience with claims management software and data analytics tools.
• Professional certifications such as Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) are a plus.

Technical Skills and Relevant Technologies

• Proficient in claims processing software and electronic health record (EHR) systems.
• Strong understanding of coding systems, including CPT, ICD-10, and HCPCS.
• Experience utilizing data analytics tools to drive decision-making and process improvements.

Soft Skills and Cultural Fit

• Excellent communication skills, with the ability to convey complex information clearly and effectively to diverse audiences.
• Strong problem-solving skills, with a proactive approach to identifying and resolving issues.
• Ability to work collaboratively in a team-oriented environment, while also demonstrating initiative and independence.
• A commitment to ethical standards and patient advocacy in the claims examination process.

Benefits and Perks

Competitive salary based on experience: [$SALARY_RANGE]

Additional benefits may include:

• Comprehensive health, dental, and vision insurance.
• Retirement savings plan with company matching.
• Generous paid time off policy and holidays.
• Professional development opportunities and tuition reimbursement.
• Wellness programs and employee assistance programs.

Equal Opportunity Statement

[$COMPANY_NAME] is committed to diversity in its workforce and is proud to be an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, creed, gender, national origin, age, disability, veteran status, sex, gender expression or identity, sexual orientation or any other basis protected by applicable law. We encourage applicants from diverse backgrounds to apply.

Location

This role requires successful candidates to be based in-person at our office located in [$COMPANY_LOCATION].

Company Overview

[$COMPANY_OVERVIEW]

Role Overview

We are seeking a highly skilled Claims Supervisor to join our dynamic team at [$COMPANY_NAME]. In this pivotal role, you will lead and mentor a team of claims adjusters, ensuring that all claims are processed efficiently and accurately while maintaining the highest standards of customer service. You'll leverage your expertise in claims management to drive improvements in operational processes and contribute to strategic initiatives that enhance our service delivery.

Responsibilities

• Supervise daily operations of the claims department, ensuring that all claims are evaluated and processed in accordance with company policies and regulatory requirements.
• Provide guidance and support to claims adjusters, fostering a collaborative team environment focused on continuous improvement.
• Conduct regular performance evaluations and provide coaching to team members to enhance their skills and effectiveness.
• Analyze claims data to identify trends and recommend process enhancements aimed at improving efficiency and accuracy.
• Collaborate with internal stakeholders, including underwriting and legal departments, to resolve complex claims issues.
• Ensure compliance with state and federal regulations affecting claims processing.
• Develop and implement training programs for new hires and ongoing education for existing staff.

Required and Preferred Qualifications

Required:

• 5+ years of experience in claims management or a related field, with at least 2 years in a supervisory capacity.
• Strong understanding of claims processing systems and insurance regulations.
• Proven ability to lead teams and drive operational excellence.
• Exceptional analytical and problem-solving skills, with experience in data-driven decision making.

Preferred:

• Bachelor's degree in Business Administration, Insurance, or a related field.
• Professional certifications such as AIC, CPCU, or similar.
• Experience with process improvement methodologies such as Six Sigma or Lean.

Technical Skills and Relevant Technologies

• Proficiency in claims management software and systems, with the ability to leverage technology to streamline processes.
• Familiarity with data analysis tools and reporting software.
• Understanding of CRM systems and their integration in claims processing.

Soft Skills and Cultural Fit

• Exceptional verbal and written communication skills, with the ability to articulate complex information clearly and effectively.
• Strong leadership presence and the ability to inspire and motivate team members.
• Ability to navigate challenges with diplomacy and tact, ensuring a positive work environment.
• A commitment to delivering exceptional customer service and fostering a culture of accountability.

Benefits and Perks

We offer a competitive salary range of [$SALARY_RANGE], along with a comprehensive benefits package that includes:

• Health, dental, and vision insurance
• Retirement savings plans with company matching
• Generous paid time off and holiday schedule
• Professional development opportunities and training programs
• Flexible work arrangements to support work-life balance

Equal Opportunity Statement

At [$COMPANY_NAME], we believe in fostering a diverse and inclusive workplace. We are proud to be an Equal Opportunity Employer and encourage all qualified applicants to apply. All candidates will be considered for employment without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, disability, or veteran status.

Location

This is a hybrid position, with successful candidates expected to work from the office at least 3 days a week while maintaining the flexibility to work remotely.

Company Overview

[$COMPANY_OVERVIEW]

Role Overview

We are seeking a highly skilled Claims Manager to lead our claims operations and enhance our service quality. In this role, you will be responsible for overseeing the entire claims process, ensuring compliance with regulations, and driving strategic initiatives to improve efficiency and customer satisfaction.

Responsibilities

• Manage the claims team, providing guidance and support to ensure timely and accurate processing of claims.
• Develop and implement best practices and standard operating procedures for claims handling.
• Analyze claims data to identify trends, resolve complex issues, and implement solutions that improve operational efficiency.
• Coordinate with cross-functional teams, including underwriting, legal, and customer service, to address claims-related inquiries and issues.
• Ensure compliance with regulatory requirements and internal policies, conducting audits and training sessions as necessary.
• Foster a culture of continuous improvement within the claims department, encouraging innovation and the adoption of new technologies.

Required and Preferred Qualifications

Required:

• 5+ years of experience in claims management or a related field.
• Strong knowledge of insurance products and claims processes.
• Proven leadership skills with the ability to effectively manage a diverse team.
• Excellent analytical and problem-solving abilities.
• Exceptional communication and interpersonal skills.

Preferred:

• Bachelor's degree in Business Administration, Finance, or a related field.
• Experience with claims management software and data analysis tools.
• Professional certifications such as CPCU or AIC are a plus.

Technical Skills and Relevant Technologies

• Proficient in claims management systems and Microsoft Office Suite.
• Experience with data analytics tools to assess claims metrics.
• Familiarity with regulatory compliance standards in the insurance industry.

Soft Skills and Cultural Fit

• Strong leadership presence with the ability to inspire and motivate a team.
• Ability to navigate complex issues and make data-driven decisions.
• Proactive approach to problem-solving with a commitment to excellence.
• Adaptable and open to change in a dynamic work environment.
• Strong customer service orientation, ensuring claims are handled with care and empathy.

Benefits and Perks

Annual salary range: [$SALARY_RANGE]

Additional benefits may include:

• Health, dental, and vision insurance.
• 401(k) plan with company matching.
• Generous paid time off and holidays.
• Professional development opportunities.
• Flexible work hours and a supportive remote work environment.

Equal Opportunity Statement

[$COMPANY_NAME] is committed to creating a diverse environment and is proud to be an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, creed, gender, national origin, age, disability, veteran status, sex, gender expression or identity, sexual orientation, or any other basis protected by applicable law.

Location

This is a fully remote position.