Vice President, Audit Project Leader, Enterprise Resilience
BNY
Medical Claims Specialist, Remote
Gainwell Technologies
full-time
Posted on:
Origin: • 🇺🇸 United States • Virginia, West Virginia
Visit company websiteSalary
💰 $28,500 - $40,700 per year
Job Level
JuniorMid-Level
About the role
- 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.
- 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.
Requirements
- 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.
