Job Description

Job Summary:

We are seeking a detail-oriented and experienced Claim Examiner with a strong background in nursing and medical knowledge to join our team. The ideal candidate will leverage their clinical expertise and minimum of five years of experience in the assistance industry to evaluate and process insurance claims accurately and efficiently. This role requires a deep understanding of medical terminology, procedures, and standards of care, combined with analytical skills to ensure claims align with policy terms and regulatory requirements.

Key Responsibilities:

Review and analyze insurance claims to determine validity, accuracy, and eligibility based on policy guidelines and medical documentation.

Apply medical knowledge to assess diagnoses, treatments, and procedures outlined in claims for consistency and appropriateness.

Investigate complex claims by collaborating with healthcare providers, policyholders, and other stakeholders to gather additional information as needed.

Ensure compliance with company policies, industry regulations, and legal standards in claims processing.

Provide clear and concise explanations for claim approvals, denials, or adjustments to internal teams and claimants.

Maintain accurate records and documentation of all claim decisions and communications.

Identify potential fraud or abuse patterns in claims and escalate issues for further review.

Assist in training or mentoring team members on medical-related claim inquiries as needed.

Qualifications:

Education: Registered Nurse (RN) or equivalent nursing certification required; bachelor's degree in nursing or a related field preferred.

Experience: Minimum of 5 years of experience in the assistance industry (assistance company or medical claims processing).

Medical Knowledge: Strong understanding of medical terminology, anatomy, physiology, and standard healthcare practices.

Skills:

Excellent analytical and problem-solving abilities.

Proficiency in reviewing medical records and interpreting clinical data.

Strong attention to detail and organizational skills.

Effective communication skills, both written and verbal, to interact with claimants and healthcare professionals.

Familiarity with insurance policies, claims processing systems, and regulatory compliance.

Technical Proficiency: Comfortable using claims management software and standard office tools.

Certifications: Additional certifications in medical coding, billing, or insurance claims are a plus.

Preferred Attributes:

Prior experience as a claim examiner or in a similar role within the insurance industry.

Ability to work independently and manage multiple priorities in a fast-paced environment.

Commitment to maintaining confidentiality and handling sensitive information with integrity.

Work Environment:

Full-time position, remote work.

Collaborative team setting with opportunities for professional growth and development.

Salary & Benefits:

Competitive salary commensurate with experience.

Comprehensive benefits package including health insurance, personal days off and paid time off.

Job Type: Full-time

Benefits:

Extended health care
Work Location: Remote