Claims Examiner Job Description template and pdf with duties [2024]

Job summary 1

The Claims Examiner reports to the Supervisor of Claims. The claims Examiner is responsible for reviewing and processing medical, dental, vision, and electronic claims by state, federal, and health plan regulatory requirements, and department guidelines, as well as meeting established quality and production performance benchmarks to include research and review of applicable documentation. The Claims Examiner will thoroughly review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position will assist in resolving issues from providers, customer service, member services, health plans, and other internal customers.

Duties & Responsibilities 1

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Adjudicate all claims types including Dental, Vision, and Medical claims for inpatient and outpatient facilities, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident, and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
Analyze patient and medical information to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization or Coordination of Benefits is necessary and process claims accordingly.
Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation.
Resolve benefit and eligibility issues that require detailed knowledge, support for customers within the claims processing, Company and ERISA guidelines. Process low-level claims, and re-pricing corrections.
- Research and complete all correspondence related to electronic and paper claims as
- Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client and enrollee data.
- Meet and maintain individual and department productivity and quality standards.

Requirements & Skills 1

High school education or equivalent: minimum one (1) to three (3) years year of experience as a Health Claims Examiner or comparable industry experience preferred.
A minimum of one (1)year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims
Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and/or benefit determination
Basic knowledge of medical terminology. Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
Good verbal and written communication skills.
- Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
- Ability to work under pressure and adapt to a changing environment
- Working knowledge of Employee Retirement Income Security Act of 1974 (ERISA) claims processing/adjudication guidelines.

Job summary 2

Our Claims department is currently seeking a Claims Examiner to manage and oversee file load involving simple to moderate complexity subrogation losses. Provides support, insight, and/or direction to field claims reps in the pursuit of subrogation through several methods including direct, arbitration, litigation, or collection. Includes communications with payers, attorneys, agents, and/or insureds on the cases to achieve a positive and fair outcome. Also includes administrative-type procedures instrumental to the Claims Recovery operations.

Duties & Responsibilities 2

Review subrogation exposure claim files for procedural and compliance issues
Perform specific file review methods
- Review incoming payment receipts for accuracy and timeliness Ensure their prompt posting
- Work with field associates, attorneys, and agents on claim and subrogation matters
- Ensure compliance with existing subrogation processes as well as assist in the development of new processes to improve efficiencies

Requirements & Skills 2

Knowledge of Microsoft Word, Excel, and Adobe with a preferred emphasis on Excel
Ability to learn claims handling basics and statutory requirements to ensure compliance
Good verbal and written communication skills
Sbility to concentrate and pay attention to detail
Strong decision making skills
Knowledge of the Claims Management System is preferred
- High school diploma (or equivalent) or higher
- willingness to complete three parts of the Associate in Claims program within three years
- willing to complete the Claims Basic School

Job summary 3

The Claims Examiner maintains a full caseload of Professional Liability claims. The ideal candidate would have experience handling lawyers, accountants, miscellaneous professional liability claims, and/or healthcare claims. Analyzes and reviews claims for accuracy, completeness, and coverage. Prepares and maintains reports and records for processing.

Duties & Responsibilities 3

Requirements & Skills 3

J.D. degree required.
Minimum 3 years relevant claims/law firm experience.
- Prior Professional Liability Claims and law firm experience defending professionals preferred.
- Good interpersonal, presentation, written, and verbal communication skills, ability to effectively negotiate, analytical, organizational, numerical, and verbal reasoning skills
- Proficient in Microsoft Office, Internet software, Database software

Job summary 4

We are searching for a Claims Examiner - someone who works well in a fast-paced setting. In this position, you will process and adjudicate claims received for reimbursement to Providers based on an extensive review, research, and a detailed format of claim processing procedures.

Duties & Responsibilities 4

Thoroughly reviews, investigates, and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time
Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days
The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports
- The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review
- The claims that are manually adjudicated must have notes entered as reviewed by weekly audits, check runs, returned claims, and management review 98% of the time
- Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication

Requirements & Skills 4

Being fully vaccinated against COVID-19 is required for all employees unless approved for a medical or religious exemption
High school diploma or GED required
1 year claims examination experience required

Job summary 5

We are looking for a full-time Claims Examiner. Primary duties will be to ensure claim payments are issued promptly and accurately under the terms of various Long Term Care policies (including Nursing Home, Assisted Living, and Home Health Care benefits). Obtain proof of loss documentation from claimants and care providers, analyze information against the policy provisions, and make an independent benefit eligibility determination using professional judgment, skill, and policy-interpretation experience.

Duties & Responsibilities 5

Ensures that claims payments are issued promptly and accurately.
Communicates with internal and external customers via phone, fax, and mail to obtain the necessary information to review benefit payment eligibility
Ensures that claims handling is conducted in compliance with applicable statutes, regulations, and other legal requirements and that all applicable company procedures and policies are followed.
- Investigate coverage for Long Term Care benefit eligibility, including the level of care changes, and functional reassessment intervals.
- Request applicable medical documentation from appropriate parties for eligibility review.
- Accept or deny liability based on an independent evaluation of functional assessments, plans of care, medical records, state regulations, state licensure requirements, and policy provisions.

Requirements & Skills 5

Job summary 6

The Claims Examiner position is responsible for the investigation, adjustment, and settlement of Homeowner Property claims.

Duties & Responsibilities 6

Requirements & Skills 6

Bachelor’s degree from a regionally accredited university in associated discipline or equivalent experience
1 to 3 years of property claim handling experience or general knowledge of property insurance and property claims handling.
Strong negotiation and communication skills.
- Current Florida adjuster’s license
- Computer literacy in Microsoft Word, Excel, and Outlook.
- Ability to communicate effectively both orally and in writing

Job summary 7

The Claims Examiner reviews and evaluates paper & electronic claims for benefits in accordance with policy provisions

Duties & Responsibilities 7

Evaluate claim material to determine eligibility
Ensure policy benefits are paid accurately, if applicable
Apply benefits on every applicable policy
Request additional information when required
Apply appropriate denial codes if no benefits are payable
Independent worker
- May interface with outside vendors or other departments within the organization
- Assists with special projects
- May be a Subject Matter Expert in some areas

Requirements & Skills 7

High-school diploma or equivalent
Typically has 2 years of experience with health insurance claims
Knowledge & understanding of ICD-10, CPT, & HCPCS codes
Understanding of HIPPA guidelines
- Understands basic medical terminology
- Basic computer skills
- Familiar with Microsoft Office, Outlook, Word & Excel

Job summary 8

The Claims Examiner reports to the Supervisor of Claims. The claims Examiner is responsible for reviewing and processing medical, dental, vision, and electronic claims by state, federal, and health plan regulatory requirements, and department guidelines, as well as meeting established quality and production performance benchmarks to include research and review of applicable documentation. The Claims Examiner will thoroughly review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorizations, and process them for payment. The position will assist in resolving issues from providers, customer service, member services, health plans, and other internal customers.

Duties & Responsibilities 8

Adjudicate all claims types including Dental, Vision, and Medical claims for inpatient and outpatient facilities, physician claims, In and Out of Network claims, Medicaid reclamation (HIPD), outpatient lab and radiology, accident, and Third-Party Liability (TPL) claims, by calculating benefit due to approve or deny, based on SPD and within accepted corporate cycle timeframe.
Analyze patient and medical information to identify instances where investigation for determining appropriate Claim Benefits, Pricing, Prior Authorization, or Coordination of Benefits is necessary and process claims accordingly.
Examine claim files for accuracy: verifications (i.e. eligibility, medical authorization, etc.); reach out to Health Care Providers to obtain necessary claims documentation.
Resolve benefit and eligibility issues that require detailed knowledge, and support for customers within the claims processing, Company, and ERISA guidelines. Process low-level claims and re-pricing corrections.
- Research and complete all correspondence related to electronic and paper claims as
- Maintain a Health Insurance Portability and Accountability Act (HIPAA) compliant workstation. Utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client and enrollee data.
- Meet and maintain individual and department productivity and quality standards.

Requirements & Skills 8

High school education or equivalent: minimum one (1) to three (3) years year of experience as a Health Claims Examiner or comparable industry experience preferred.
A minimum of one (1)year experience as a Claims Examiner for medical, dental claims and vision, subrogation, and accident claims
Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for accurate claim adjudication and/or benefit determination
Basic knowledge of medical terminology. Familiar with UB-04 and HCFA 1500 forms (837/5010 format), ICD10, CPT, and HCPCS codes.
- Good verbal and written communication skills.
- Proficient in 10-key by touch data entry/type 40 WPM and Microsoft Office (Word, Excel, Outlook, PowerPoint) and possess a capability to quickly learn new applications.
- Ability to work under pressure and adapt to changing environment

Job summary 9

The Claims Examiner will process claims for employee benefits and other benefit plans.

Duties & Responsibilities 9

Process medical, dental, and vision claims in full accordance with the current and relevant provisions of applicable plan documents
Monitor and highlight high-cost claims and ensure relevant parties are aware.
Meet or exceed minimum standards of productivity and accuracy minimums for payment, procedure, and financial goals
Actively support other team members and provide resources to enable all team goals to be achieved.
Be able and willing to temporarily be assigned to other accounts as inventory/situations require
Prepare correspondence in a clear, concise manner and retain a copy for our files
- Monitor and manage individual pend reports and scanning queues, taking accurate and timely action and assisting others with pend reports as needed
- On occasion may be required to assist with special projects
- On occasion may be required to work overtime

Requirements & Skills 9

Experience handling and processing healthcare and medical claims
- Proficiency in Excel
- Proficiency in data entry
- Written and oral communication

Job summary 10

We are seeking a skilled Claims Examiner to handle claims at our growing, innovation-focused company. A qualified candidate will have strong estimating skills, can comfortably handle high-severity losses, and distill complex information for customers. You’ll be able to effectively communicate and negotiate across multiple parties, including customers, contractors, and public adjusters. This is a desk-based adjusting position. If you're interested in joining our growing Claims team, we'd love to hear from you.

Duties & Responsibilities 10

Investigate and document property claims, including policy review, recorded statements, assigning inspections, updating reserves, preparing or reviewing estimates, and negotiating settlements
Communicate claim updates and decisions verbally and in writing
Handle claims in compliance with all applicable regulations and internal processes
Provide technical expertise and serve as an SME for Claims-related projects
- Act as a resource for less experienced staff
- Support catastrophe response as needed, including potential overtime and deployment
- Any other duties needed to help drive our purpose and fulfill our values

Requirements & Skills 10

5+ years of property claims experience
Estimating skills
Excellent written and verbal communication skills
- Strong organizational abilities
- Empathetic interpersonal skills
- Adjuster licensed in the home state or holds a non-resident license if license not required; meets requirements for licensing in additional states as needed

Claims Examiner Job Description

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