Medical Claims Specialist - US Remote WV

Summary

The Claims Examiner is responsible for reviewing, evaluating, and processing claims in accordance with policy provisions, regulatory requirements, and organizational guidelines. This role ensures timely, accurate, and fair adjudication of claims while maintaining a high level of customer service and compliance.

Your role in our mission

• Review and analyze claim submissions, supporting documentation, and policy details.

• Determine claim eligibility, coverage, and benefits according to company policies and industry regulations.

• Request additional documentation or information as needed to finalize claim determinations.

• Accurately calculate payment amounts and authorize claim settlements.

• Maintain detailed, organized claim files and records in the claims management system.

• Communicate claim decisions clearly to policyholders, providers, or other stakeholders.

• Collaborate with internal departments (e.g., underwriting, legal, provider relations) for complex claim cases.

• Identify potential fraud, waste, or abuse and escalate cases as required.

• Ensure all claims are processed within required timelines and service-level agreements.

• Stay up to date on industry regulations, policy changes, and best practices.

What we're looking for

• High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred.

• 2+ years of claims processing or insurance industry experience preferred.

• Strong knowledge of claims adjudication procedures, policies, and regulatory requirements.

• Excellent analytical, problem-solving, and decision-making skills.

• Strong attention to detail and accuracy.

• Proficient in claims management software and Microsoft Office Suite.

• Effective written and verbal communication skills.

What you should expect in this role

• Analytical thinking

• Decision quality

• Time management

• Compliance awareness

• Customer focus

• Remote position