Position: Health Claims Examiner
We are looking for a highly motivated individual with claims processing experience for a busy health claims department. The ideal candidate will be creative, observant and very attentive to detail. You will need to be an organized self-starter that is diligent and responsive, take initiative, work well independently, maintain a positive attitude and strive to maintain the company's culture. Excellent communication, computer and problem-solving skills, and a willingness to work alongside the other members of the department are critical. The department processes a variety of claims, including medical, dental, vision, life, and short-term disability.
POSITION PURPOSE: The Health and Welfare Claims Examiner is responsible for the accurate and timely adjudication of medical, dental, vision, and life benefit claims in accordance with plan documents and regulatory guidelines. This role ensures financial integrity by verifying benefit limits and coordinating coverage, while directly supporting the Member Services team to resolve complex inquiries and deliver an exceptional experience to plan participants and providers.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
To be successful in this role, an individual must be able to perform in a satisfactory manner the functions listed below. We will make reasonable accommodations to enable individuals with disabilities to perform these functions.
ESSENTIAL FUNCTIONS
Claims Examiner Responsibilities
· Accurately adjudicate multi-line benefit claims, encompassing medical, dental, vision, and life insurance, while maintaining high production and quality standards.
· Interpret complex plan documents, Summary Plan Descriptions (SPDs), and Summary of Benefit Coverage (SBCs) to ensure accurate application of deductibles, coinsurance, out-of-pocket maximums, and fee schedules.
· Maintain strict compliance with HIPAA regulations and identify potential fraud, waste, or third-party liability issues.
· Apply Coordination of Benefits (COB) and Medicare Secondary Payer rules to determine correct primary and secondary liability.
· Serve as a subject matter expert for Member Services, analyzing historical claim processing to support the resolution of complex provider and member inquiries.
· Execute financial claim adjustments and refund processing in alignment with senior level examiner authorities (Level II Examiners only).
· Perform rigorous quality assurance and auditing of processed claims to guarantee alignment with fund benefit structures and regulatory requirements (Auditor Level only).
· Perform additional departmental duties and support special projects as required to meet operational goals.
OTHER FUNCTIONS
· Performs other administrative duties as assigned.
EDUCATION AND/OR EXPERIENCE
To perform this job successfully, an individual must have the following education and/or experience.
· High School Diploma of GED equivalent
· Level I (Entry Level): 1-2 years of experience in healthcare billing, medical office administration, or health insurance customer service.
· Level II Examiner: 3-5 years of direct experience adjudicating complex medical, dental, vision, and life claims within a third party administrator (TPA), insurance carrier, or Taft-Hartley trust fund.
· Auditor Level: 5+ years of claims adjudication experience, with at least 1-2 years specifically in a quality assurance, auditing, or senior peer review role.
KNOWLEDGE, SKILLS, AND ABILITIES
The requirements listed below are representative of the knowledge, skills, and/or abilities required to perform each essential duty satisfactorily. We will make reasonable accommodations to enable individuals with disabilities to perform these functions.
· Medical Coding: Strong familiarity with ICD-10, CPT, HCPCS, and CDT (dental) coding systems. Professional certifications like CPC (Certified Professional Coder) or CBCS (Certified Billing and Coding Specialist) are a major plus but not always mandatory for examiners.
· Regulatory Knowledge: Solid understanding of ERISA, HIPAA, COBRA, Coordination of Benefits (COB), and Medicare Secondary Payer (MSP) rules.
· Technical Proficiency: Experience using proprietary claims processing software and intermediate MS Excel skills.
· Mathematical Aptitude: Strong basic math skills for calculating deductibles, co-insurance, out-of-pocket maximums, and prorated benefits.
· Analytical Thinking: The ability to read dense Summary Plan Designs (SPDs) and apply logic to complex billing scenarios
PHYSICAL DEMANDS
The physical demands described here are representative of those an individual must meet in order to successfully perform the essential functions of this job. We will make reasonable accommodations to enable individuals with disabilities to perform these functions.
· Primarily involves sitting for extended periods (up to 8 hours per day) at a workstation or desk.
· Frequent and repetitive use of hands, wrists, and fingers for data entry, typing, mousing, and operating standard office equipment.
· Requires close visual acuity to read, analyze, and interpret dense text, medical codes, and financial data on dual computer monitors for long durations.
· Ability to effectively communicate, express, or exchange ideas verbally and in writing with members, providers, and internal teams.
· Occasional light lifting, carrying, pushing, or pulling of office objects (such as files, paper reams, or laptops) up to 10–15 pounds.
· Standard, climate-controlled office environment with a moderate noise level (e.g., computers, printers, and light vocal traffic).
· Remote Work Option: Must possess a secure, private, and distraction-free home office space with reliable high-speed internet access capable of maintaining HIPAA compliance.
LOCATION
This is a full-time position based in office or remotely. The typical work schedule is Monday through Friday, 8AM – 5PM.
Job Type: Full-time
Pay: From $19.00 per hour
Benefits:
- Dental insurance
- Employee assistance program
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Physical Setting:
Application Question(s):
- What is your hourly rate expectation?
Education:
- High school or equivalent (Preferred)
Experience:
- Healthcare: 2 years (Required)
- Medical billing: 1 year (Required)
Work Location: In person
