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Collective Health · 9 hours ago

Member Claims Examiner

Plano, TX

Full-time

Hybrid

Mid Level

$23/hr - $29/hr

3+ years exp

Collective Health is transforming how employers and their people engage with their health benefits through technology and exceptional service. As a Member Claims Examiner, you'll review and resolve complex medical claims issues while ensuring regulatory compliance and enhancing member experiences.

Health CareHealth InsuranceInsurTech

Responsibilities

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

Qualification

Medical claims adjudicationRegulatory complianceMedical codingAnalytical skillsMedical terminologyProblem-solving skillsPrioritization skillsCustomer service experienceIndustry certifications837 EDI formatCommunication skillsInterpersonal skillsTeam collaborationFast-paced environment

Required

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

Preferred

Bachelor's 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