Claims Examiner

Job Title: Claims Examiner  

Job Type: Full Time 

FLSA Status:  Non-Exempt/Hourly 

Grade: H2 

Function/Department: Health Plan and Healthcare Services 

Reporting to:  Team Lead/Supervisor - Operations 

Role Description:  A claims examiner needs to analyse multiple documents / contracts and decide to pay / deny the claim submitted by member or providers with respect to client specifications. The claims examiner should also route the claim to different department or provider / member for any missing information that required for claims adjudication. The claims need to be completed adhering to required TAT and quality SLA. 

Key Responsibilities  

• Should have Excellent Analytical skills to review claims based on rules and workflows.  

• Need good comprehension skills to adjudicate claims as per Policies and Procedures.  

• Should be a complete team player   

Key Performance Indicators:  

• Ensuring that the key Service Level Agreements are met consistently without any exceptions.  

• Achieve set Production goals.  

• Adherence to departmental and company rules and regulations. 

Qualifications 

The qualifications listed below are representative of the background, knowledge, skill, and/or ability required to perform their duties and responsibilities satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. 

Education                 

• High School diploma or equivalent required  

Competencies & Skills 

• Highly-motivated and success-driven  

• Exceptional verbal and written communication and interpersonal skills, including negotiation and active-listening skills 

• Exceptional analytical and problem-solving skills  

• Strong attention to detail with a commitment to accuracy 

• Ability to adapt to change in a dynamic fast-paced environment with fluctuating workloads 

• Basic mathematical skills 

• Intermediate typing skills 

• Basic computer skills  

• Knowledge of medical terminology, ICD-9/ICS-10, CPT, and HCPCS coding, and HIPAA regulations preferred 

• Knowledge of insurance policies, regulations, and best practices preferred 

Additional Qualifications 

• Ability to download 2-factor authentication application(s) on personal device, in accordance with company and/or client requirements 

• Ability to pass the required pre-employment background investigation, including but not limited to, criminal history, work authorization verification and drug test 

Work Environment 

The work environment characteristics described here are representative of those an employee encounters while performing this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

This position may work onsite or remotely from home.   

Physical Demands 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

Must be able to regularly or frequently talk and hear, sit for prolonged periods, use hands and fingers to type, and use close vision to view and read from a computer screen and/or electronic device.  Must be able to occasionally stand and walk, climb stairs, and lift equipment up to 25 pounds.  

Firstsource is an Equal Employment Opportunity employer.  All employment decisions are based on valid job requirements, without regard to race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, age, disability, genetic information, veteran status, or any other characteristic protected under federal, state or local law.    

About Firstsource  

Firstsource Solutions is a leading provider of customized Business Process Management (BPM) services. Firstsource specialises in helping customers stay ahead of the curve through transformational solutions to reimagine business processes and deliver increased efficiency, deeper insights, and superior outcomes.  

We are trusted brand custodians and long-term partners to 100+ leading brands with presence in the US, UK, Philippines, India and Mexico. Our ‘rightshore’ delivery model offers solutions covering complete customer lifecycle across Healthcare, Telecommunications & Media and Banking, Financial Services & Insurance verticals.  

Our clientele includes Fortune 500 and FTSE 100 companies.