Medical Claims Examiner

Caprock HealthPlans – A 90 Degree Benefits Company
San Antonio, TX Full Time
POSTED ON 4/25/2023 CLOSED ON 7/24/2023

Job Posting for Medical Claims Examiner at Caprock HealthPlans – A 90 Degree Benefits Company

Job Summary:

The ideal candidate will be responsible for processing and adjudicating medical, dental, vision, flex and or disability claims according to the industry standards and practices. The examiner must meet high quality and production standards as defined by management and be able to interpret plan contract language and apply appropriate benefit coverages based on the plan provisions outlined in the Plan Document.

Essential Functions:

  • Process complex claims for physician, hospital and specialty areas with high degree of accuracy and productivity.
  • Process adjustments, refunds and return checks according to company policies and procedures
  • Process claims to established dollar authority.
  • Respond timely to all written appeals and Department of Insurance requests.
  • Complete stop loss disclosure packets and process stop loss claims accurately and timely.
  • Handle all claim negotiations and case management claims accurately and timely.
  • Assists in customer service calls when necessary without sacrificing quality.
  • Tests new benefits, new client implementations or product enhancements.
  • Provides assistance and serves as a mentor to team members.
  • Assist Director in providing reports when necessary.
  • Identifies process improvement opportunities and works to implement corrective actions.
  • Assist with claims documentation, training and education.
  • Overtime, as required.
  • Prompt and regular attendance
  • Travel, as required.

Qualifications:

  • Minimum 5 years Medical claims examining/ processing background, with progressive responsibilities.
  • Knowledge of medical terminology and coding rules.
  • Excellent written and verbal communication skills.
  • Knowledge of MS Office products.
  • Demonstrated knowledge of stop loss filings and compliance rules.
  • Highly organized and detail oriented.
  • Identifies ways to meet and exceed customer expectations.
  • Able to work and adjust priorities in a fast paced environment.
  • Previous leadership experience is desired.

Physical Requirements:

While performing this job, the employee is frequently required to sit, talk, and hear. The employee may occasionally lift and/ or move up to 30 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

The work is primarily in an office setting. The noise level in the work environment is moderate.

The duties listed above are intended only as an illustration of duties, and not an all inclusive list. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or logical to the position.

Job Type: Full-time

Benefits:

  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Employee assistance program
  • Health insurance
  • Life insurance
  • Paid time off
  • Vision insurance

Schedule:

  • Monday to Friday

Education:

  • High school or equivalent (Preferred)

Experience:

  • Medical claim adjudication: 5 years (Required)
  • Third Party Administator, self fund insurance: 2 years (Preferred)
  • Medical terminology and coding: 2 years (Required)

Work Location: One location

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