Medical Claims Examiner

Health Insurance Medical Claims Examiner

Health Insurance Medical Claims Examiner (Initial Training On Site - 90 days - Remote position after training in FL)

Must live within a reasonable commuting distance of Clearwater, FL

Monday-Friday Schedule with daytime hours

Responsibilities

Summary : The Medical Claims Examiner adjudicates medical claims based on health policy provisions and established guidelines.

Essential Duties and Responsibilities :

• Reviews and adjudicates medical claims based on health policy provisions and established guidelines
• Requests additional information from members and providers as needed
• Initiates and completes claim investigations when indicated including pre-existing conditions, accidents, medical necessity and appropriateness, eligibility and coordination of benefits
• Documents fully claims referred to senior staff for review and determination
• Maintains company production and quality standards
• Participates in training

Other Responsibilities :

Supervisory Responsibilities : None

Competencies :

Qualifications

Qualifications :

Education and / or Experience :

High school diploma or equivalent is required

Certificates, Licenses, Registrations :

None

Computer Skills :

Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook

Environmental Factors / Physical Demands :

Training is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.