Claims Examiner

The Opportunity

Health

EZ is seeking a highly motivated Claims Examiner who combines exceptional analytical and problem‑solving skills, can comprehend and adjudicate medical and dental claims in adherence to the group’s Plan Document, maintain accurate claim records and can positively adapt to change in a fast‑paced environment. This person must possess the ability to work effectively in an environment with fluctuating workloads and designated deadlines.

The Claims Examiner will report to the Manager, Claims Operations.

• Adjudicate medical and dental claims accurately and timely by applying company policies and the Plan summary of benefits
• Examine claims, identifying duplicates, mispriced or miscoded claims, etc.
• Adjudicate according to Plan Summary Documentation (SPD) and other claims adjudication rules such as coordination of benefit (COB), code editing and payment integrity claims rules
• When necessary, reprice claims, using the network’s proprietary portal
• Enter manual claims received from Members or Providers
• Other duties as assigned

What We Expect From You:

• High School diploma or equivalent
• 5 years of claims processing experience in a TPA setting – preferred
• Experience with Plan Summary documentation for Health plans
• VBA experience or similar claims systems experience
• Familiarity with CPT, ICD
  10, & HCPCS codes
• Experience interpreting Summary Plan Documents (SPD)
• Self‑Starter and ability to work independently
• Highly collaborative and able to function well in a team environment
• Highly organized with great attention to detail
• Ability to learn new systems efficiently & effectively
• We make healthcare EZ!

• Factors that may be used to determine your actual salary include your job‑specific skills, education, training, job location, number of years of experience related to this role and comparison to other employees already in this role.

Employee benefits are part of the competitive total rewards package that Health

EZ provides to you. Our comprehensive benefits program includes health benefits, retirement plan (401k), paid time away, paid leaves (including paid parental leave) and more.

Health

EZ recognizes its responsibilities under federal, state, and local laws requiring non‑discriminatory employment practices. All employment decisions, practices and procedures will be carried out without regard to race, color, creed, religion, sex (including pregnancy), sexual orientation, national origin or ancestry, age, marital status, disability, family status, status with regard to public assistance, or any other characteristic protected under applicable local, state, and federal laws.

Health

EZ is proud to be an equal opportunity employer.