Claims Examiner

Wellcove

Claims Examiner responsible for accurate, timely adjudication of long-term care insurance claims. Ensuring compliance with regulations while delivering high customer service to stakeholders.

Posted 7/29/2026full-timeRemote • Florida • 🇺🇸 United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in adjudicating claims, including HP/AD claims, while ensuring compliance with HIPAA regulations and company guidelines. Proficient in medical terminology, ICD 10, CPT, and revenue codes, with strong problem-solving skills and attention to detail.

Highest-signal resume keywords

Claims AdjudicationKnowledge of ICD 10Experience in US HIP ClaimsProblem-Solving SkillsMedical Terminology

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationKnowledge of ICD 10Knowledge of CPTRevenue CodesCalculating Claim AmountsRoot Cause AnalysisReading Medical DocumentsUnderstanding Surgery ProceduresInpatient vs Outpatient ClaimsBasic Math Knowledge

Soft Skills

Attention to DetailPositive ApproachOpen to LearningAbility to Handle Work PressureTime Management

Industry Keywords

HIPAA ComplianceMedical TerminologyClaims ProcessingHealth InsuranceAdjudication Processes

About the role

Key responsibilities & impact

Manage and handle all Outbound calls and adjudicate claims.
Adjudicating HP/AD claims.
Handling all Outbound calls.
Should be able to prioritize work and adjudicate claims as per turnaround time.
Job involves working independently on researching, reviewing, summarizing, and recommending a course of action on claims where an appeal or a grievance has been filed for a denied / under payment.
To ensure claims are adjudicated as per the client/company guidelines. Provide continual evaluation of processes and procedures.
To respond to and resolves claims received via emails.
Candidate should be able to correctly calculate claim amounts for the customers.
Complying with company regulations regarding HIPAA, confidentiality, and private health information.

Requirements

What you’ll need

Should have knowledge of medical terminology, human anatomy with basic math knowledge of calculating simple interest, compound interest.
Should have excellent problem-solving skills with an eye for detail, to be able to do root cause analysis of complex claims.
Should have a positive approach and open to learning process dynamics.
Ready to handle work pressure and ensure deliverables within timelines.
Experience in handling US HIP claims.
Should have knowledge of ICD 10, CPT, Surgery procedures, Revenue codes, medical terminology, medical documents, Inpatient vs Outpatient claims etc.
Should have some experience in reading and comprehending medical documents.

Benefits

Comp & perks

Collaborative team spirit.
Accountable and able to work remotely and independently.
Able to pass background screening and drug tests pre and post hire – includes THC
Verification of high school, GED, or college diploma upon request.
Timely responses from three professional references.
Able to provide a dedicated remote work location free from background noises, interruptions, and desk clutter.
Able to provide an ongoing reliable internet connection and access to a smart phone for Multi Factor Authentication and communication purposes.