Claims Examiner

Job Title: Claims Examiner

Job Type: Full Time

Grade: H

Function/Department: Health Plan and Healthcare Services

Reporting to: Team Leader -Operations

Pay Rate: $16/hr

Role Description: We are seeking a highly-motivated and success-driven Claims Examiner who combines exceptional analytical and problem-solving skills, with the ability to positively adapt to change in a dynamic fast-paced environment. It is also vital that you display exceptional verbal and written communication, negotiation and active-listening skills, as well as the ability to work effectively in an environment with fluctuating workloads.

Roles & Responsibilities

• Review insurance claims to assess their validity, completeness, and adherence to policy terms and conditions.
• Collect, organize, and analyze relevant documentation, such as medical records, accident reports, and policy information.
• Ensure that claims processing aligns with the company's insurance policies and relevant regulatory requirements.
• Conduct investigations when necessary, which may include speaking with claimants, witnesses, and collaborating with field experts.
• Analyze policy coverage to determine the extent of liability and benefits payable to claimants.
• Evaluate the extent of loss or damage and determine the appropriate settlement amount.
• Communicate with claimants, policyholders, and other stakeholders to explain the claims process, request additional information, and provide status updates.
• Make recommendations for claims approval, denial, or negotiation of settlements, and ensure timely processing.
• Maintain accurate and organized claim files and records.
• Stay updated on industry regulations and maintain compliance with legal requirements.
• Provide excellent customer service, addressing inquiries and concerns from claimants and policyholders.
• Strive for high efficiency and accuracy in claims processing, minimizing errors and delays.
• Stay informed about industry trends, insurance products, and evolving claims management best practices.
• Generate and submit regular reports on claims processing status and trends

Preferred Educational Qualifications

• High School diploma or GED

Preferred Work Experience

• Health claims processing experience is required

Competencies & Skills

• Knowledge in the following:
• medical terminology
• ICD-9/ICS-10, CPT, and HCPCS coding
• HIPAA regulations
• PC applications and systems
• Ability to read and interpret general business correspondence, procedure manuals, and specific plan documents
• Basic mathematical skills
• Intermediate typing skills
• Multiple computer application usage experience
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.
• Proficient in using claims processing software and related tools.
• Detail-oriented with a commitment to accuracy.
• Knowledge of insurance policies, regulations, and best practices

About Firstsource

Firstsource Solutions is a leading provider of customized Business Process Management (BPM) services. Firstsource specialises in helping customers stay ahead of the curve through transformational solutions to reimagine business processes and deliver increased efficiency, deeper insights, and superior outcomes.

We are trusted brand custodians and long-term partners to 100+ leading brands with presence in the US, UK, Philippines, India and Mexico. Our ‘rightshore’ delivery model offers solutions covering complete customer lifecycle across Healthcare, Telecommunications & Media and Banking, Financial Services & Insurance verticals.

Our clientele includes Fortune 500 and FTSE 100 companies