Member Claims Examiner
Member Claims Examiner
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Job Description
At Collective Health were transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology compassionate service and world-class user experience design.
As a Member Claims Examiner youll play a critical role in reviewing and resolving complex medical claims issues leveraging your expertise in medical plan operations to drive accurate and timely claim adjudication. With a focus on delivering exceptional member experiences youll utilize your in-depth knowledge of regulatory requirements network partner relationships and medical coding to expertly investigate and resolve intricate member issues ensuring seamless integration of claims processing and member services.
Were seeking an experienced professional to join our team bringing advanced analytical and problem-solving skills to review and resolve complex medical insurance claims. Youll work closely with our teams to ensure seamless integration of claims processing member services and regulatory compliance driving exceptional results and member satisfaction.
What youll do:
- Review and adjudicate complex medical insurance claims applying industry expertise and knowledge of regulatory requirements
- Conduct in-depth investigations and analysis to resolve member issues ensuring timely and accurate resolutions
- Maintain expertise in medical plan operations including claims processing network partner relationships and medical coding
- Collaborate with cross-functional teams to identify and implement process improvements enhancing efficiency and member experience
- Provide expert guidance and support to junior team members sharing knowledge and best practices
To be successful in this role youll need:
- 3 years of experience reviewing and adjudicating medical insurance claims in a Third-Party Administrator (TPA) or health insurance setting
- Proven analytical and problem-solving skills with ability to navigate complex claims issues
- Strong knowledge of medical plan operations including claims processing regulatory requirements and medical coding
- Familiarity with medical terminology anatomy and physiology to accurately interpret medical records and claims data.
- Excellent communication and interpersonal skills with ability to collaborate with diverse stakeholders
- Ability to work in a fast-paced environment prioritizing multiple tasks and deadlines
Nice To Have:
- Bachelors degree or 5 years of health insurance customer servicing experience
- Experience interpreting and applying plan documents including Summary Plan Descriptions (SPDs) and other relevant plan documents to determine claim payment and benefits
- Previous experience working with and following regulatory requirements such as HIPAA ACA or other healthcare-related laws and regulations
- Possess industry-recognized certifications such as CPC (Certified Professional Coder) or CCS (Certified Coding Specialist).
- Familiarity with the 837 EDI format with the ability to read interpret and apply claims data to resolve complex claims issues.
Pay Transparency Statement
This is a hybrid position based out of our Plano office with the expectation of being in office at least three weekdays per week. #LI-hybrid
The actual pay rate offered within the range will depend on factors including geographic location qualifications experience and internal equity. In addition to the hourly rate you will be eligible for stock options and benefits like health insurance 401k and paid time off. Learn more about our benefits at TX Pay Range
Why Join Us
- Mission-driven culture that values innovation collaboration and a commitment to excellence in healthcare
- Impactful projects that shape the future of our organization
- Opportunities for professional development through internal mobility opportunities mentorship programs and courses tailored to your interests
- Flexible work arrangements and a supportive work-life balance
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race religion color national origin gender sexual orientation age marital status veteran status or disability status. Collective Health is committed to providing support to candidates who require reasonable accommodation during the interview process. If you need assistance please contact .
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Employment Type
Full Time
