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Claims Examiner - Healthcare Claims Processing

Job Category: Claims Processing

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Location: Lake Mary, FL, United States

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Job Description


The Claims Examiner will be responsible for processing complex medical and facility claims accurately through Healthfirst’s claims processing system. This is a fast-paced and high volume environment. The Claims Examiner will be expected to maintain production and quality standards as they process and adjudicate daily claims. This is a team environment position. The Claims Examiner must be able to effectively work with others, provide and implement claims processing solutions while understanding process flows. At the discretion of the Claims Manager, this position will transition into a telecommuting role (full time) following an initial training period.

  • Review, investigate and adjudicate claims and encounters for medical services through contractual provisions in accordance with provider contracts and authorizations.
  • Process new claim suspensions and perform claim adjustments to correct erroneous payments (overpayments/underpayments) as well as review other documentation for edits and consistency. All errors must be documented according to Healthfirst policies and procedures.
  • Complete Special Projects as required and as directed by Manager or Director
  • Absorb, retain and apply wide range of information about the company policies, procedures and benefits.
  • Meet individual and department standards with regards to both quality and productivity goals.
  • Additional duties as assigned

Minimum Qualifications:

  • Experience within a medical claims billing environment where you have processed and adjudicated medical or facility claims. 
  • Experience working with multiple Excel spreadsheets which will include filtering and updating information on a daily basis. 
  • Competency with navigating a keyboard and ability to enter data with speed and accuracy. 
    Prior experience managing high volume claims workload. This is a fast paced environment.
  • The Claims Examiner will be expected to meet individual and departmental standards with regards to quality and productivity. 
  • High School diploma or GED from an accredited institution.

Preferred Qualifications:

  • Associate's degree or higher from an accredited institution.
  • ICD-10/Coding Certificate.
  • The ability to type 40 + WPM.
  • Knowledge of medical terminology, ICD-10, CPT-4 and Healthcare Common Procedure Coding System (HCPCS)
  • Experience working in premium billing, COBRA administration, flexible spending and disability processing.
  • Experience processing and adjudicating claims for commercial health insurance companies, managed care organizations or other healthcare related field.
  • Familiarity with commercial insurance plans and/or Medicaid, Medicare, healthcare exchange rules and regulations.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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