Claims Examiner

Job Description

REQUIREMENTS

• High school diploma or equivalent required; associate or bachelor’s degree preferred
• 2+ years of experience in insurance claims, healthcare administration, or Long-Term Care claims processing
• Strong understanding of Long-Term Care policies, benefits, and eligibility criteria preferred
• Knowledge of medical terminology and healthcare documentation
• Proficiency in claims systems and Microsoft Office (Excel, Word, Outlook)
• Strong analytical and decision-making skills
• Excellent written and verbal communication skills
• Ability to manage multiple priorities in a fast-paced environment

RESPONSIBILITIES

• Review, evaluate, and adjudicate Long Term Care claims in accordance with policy provisions and established guidelines
• Analyze claim documentation including invoices, care plans, and provider credentials
• Apply knowledge of Coordination of Benefits (COB), Medicare, Medicaid, and other payer sources when applicable
• Ensure claims are processed within established turnaround times and service level agreements (SLAs)
• Communicate effectively with policyholders, providers, and internal teams regarding claim status, requirements, and determinations
• Identify and request additional documentation when necessary to support claim decisions
• Maintain accurate and detailed claim notes in system of record
• Ensure compliance with HIPAA and all applicable regulatory and privacy requirements
• Participate in quality assurance activities and implement feedback for continuous improvement
• Support training and mentoring of new or junior staff as needed

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