Claims Examiner

Blue Cross and Blue Shield of Kansas•New York, MO

1d•$21 - $26•Remote

About The Position

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. This position is scheduled to start December 7, 2026.

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

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