Senior Claims Examiner- Work From Home

Senior Claims Examiner - Work From Home

We are hiring a detail-oriented Senior Claims Examiner to train and work from home. The Senior Claims Examiner's primary function is to ensure the accurate adjudication of all complex claims for SCCIPA contracted plans. Your expertise will be crucial in maintaining our high standards of accuracy and efficiency in claims processing.

Compensation Highlights:

• Base Pay: $18.00 per hour

Schedule Highlights:

• Training
  
  Schedule:
  
  5 days, Monday-Friday, 8:00 AM - 5:00 PM PST

• Adjudicate all types of claims, resolving system edits and audits for hardcopy and electronic submissions
• Resolve provider and eligibility issues related to received claims
• Generate emergency reports and authorizations for claims that lack prior authorization
• Adjudicate third-party liability and coordination of benefit claims in line with policy
• Review stop loss reports and identify members approaching reinsurance levels
• Identify potential system programming issues and report them to the supervisor
• Provide technical support and training for claims processors
• Recognize and appropriately route claims for carved-out services based on plan contracts
• Process claims using knowledge of plan contracts, provider pricing, member eligibility, referral authorization procedures, benefit plans, and capitation arrangements
• Ensure correct posting of claims information to the appropriate general ledger accounts
• Collaborate with Customer Service and Provider Services on large claim projects and adjustments
• Assist with benefit and plan interpretation via the cut-log system when necessary
• Adjust complex claims and support other examiners with claim resolution
• Perform additional duties as assigned

• High school diploma or equivalent required
• Two years of experience processing both regular and complex claims
• Proficiency in ICD-9, CPT, HCPC, and revenue coding required
• Strong communication skills with the ability to collaborate effectively with supervisors, co-workers, and other departments
• Ability to analyze and resolve claims issues, troubleshooting complex problems independently
• Capable of working in a high-volume, production-oriented environment
• Detail-oriented with the ability to maintain focus during extended periods of time
• Strong performance under demanding production and quality standards
• Technical proficiency with claims processing software
• In-depth understanding of complex claims procedures and medical terminology
• Knowledge of HEDIS, DOC, HCFA, and NCQA requirements
• Ability to act as a resource and trainer for claims processors

At Broad Path, diversity is our strength. We embrace individuals from all backgrounds, experiences, and perspectives. We foster an inclusive environment where everyone feels valued and empowered. Join us and be part of a team that celebrates diversity and drives innovation!

If you need accommodation due to a disability, please email us at  This information will be held in confidence and used only to determine an appropriate accommodation for the application process.

We do not discriminate against our applicants because of race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, veteran status, genetic information, or any other status protected by applicable law.

Broad Path has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location.

Associate

Full-time

Health Care Provider

Outsourcing and Offshoring Consulting