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About the Role
A health claims examiner is responsible for reviewing, evaluating, and processing health, drug, dental and/or ancillary product claims submitted by members or providers for insurance reimbursement. The job involves ensuring that claims are processed accurately and timely, in accordance with policy terms, industry regulations, and company guidelines.
Responsibilities
- Accurately review, analyze, and verify healthcare claims submitted by policyholders or medical providers.
- Ensure all necessary documentation, coding (International Classification of Diseases, Tenth Revision (ICD-10), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS)), and data are included and correct.
- Check for eligibility, coverage, and applicable benefits as per policy terms.
- Enter and process claims information into the system with precision and attention to detail.
- Apply appropriate insurance guidelines, including deductibles, co-pays, co-insurance, and maximum coverage limits.
- Approve or deny claims based on policy coverage, ensuring compliance with regulatory and company standards.
- Perform adjustments to processed claims as needed for corrective action.
- Correspond with healthcare providers, patients, and internal departments to clarify or resolve discrepancies.
- Investigate and resolve complex or escalated claim issues, such as coding errors, benefit misunderstandings, or billing discrepancies.
- Ensure compliance with state and federal healthcare regulations.
- Supports core values, policies, and procedures
- Maintain detailed and accurate records of all claims processed, including documentation for audits or reviews.
- Meet individual and team performance targets related to claims processing speed, accuracy, and quality.
- Participate in ongoing training to stay updated on changes in health insurance policies and claims processing technologies.
- Monitor and work daily reports to ensure timely claim control.
- Performs other duties that may be assigned from time to time
Requirements
- High school diploma or equivalent required
- Previous experience in healthcare claims processing, medical billing, medical terminology, or health insurance preferred
- Strong attention to detail and organizational skills.
- Knowledge of medical claim processing, medical terminology, insurance policies, and coding standards (ICD, CPT).
- Excellent communication skills, both written and verbal.
- Ability to work efficiently under pressure and meet deadlines.
- Critical thinking and problem solving skills
- Office and/or computer system experience preferred
- Blue Cross and Blue Shield of Kansas conducts pre-employment drug screening, criminal conviction check, employment verifications and education as part of a conditional offer of employment.
Skills
- Healthcare claims processing
- Medical billing
- Medical terminology
- Health insurance
- Attention to detail
- Organizational skills
- Medical claim processing
- Insurance policies
- Coding standards (ICD, CPT)
- Communication skills
- Critical thinking
- Problem solving
- Office systems
- Computer systems
Location
- Remote
- Kansas
- Missouri
Work Type
- Remote
- Full-time
Experience Level
- Preferred experience in healthcare claims processing, medical billing, medical terminology, or health insurance
Education Level
- High school diploma or equivalent
Salary/Compensations
- $20.96 - $26.20
Benefits
- Paid vacation
- Sick leave
- Paid maternity leave
- Paid paternity leave
- Health insurance
- Vision insurance
- Dental insurance
- 6 weeks paid parental leave for new mothers and fathers
- Fertility/Adoption assistance
- 2 weeks paid caregiver leave
- 401(k) plan matching up to 5%
- Tuition reimbursement
- Health & fitness benefits, discounts and resources
About the Company
- One of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.
- Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members.
Equal Opportunity
- We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law.