Claims Examiner I

Overview

American Specialty Health Incorporated (ASH) is looking for a Claims Examiner I to join their Claims department, working remotely. The role involves verifying and processing medical claims data extracted from CMS 1500 forms using Optical Character Recognition and entering it accurately into the Claims Processing System. The examiner will review claims for completeness, ensure appropriate member and provider records are used, and adjudicate claims following organizational policies and regulations.

Remote Work Requirements

This position is fully remote and requires candidates to have a dedicated workspace at home furnished with company-provided technology. A consistent, stable internet connection with at least 50 Mbps download and 10 Mbps upload speed is mandatory; speeds of 100 Mbps down and 20 Mbps up are recommended for quality video meetings. Participation in online meetings via video is expected.

Key Responsibilities

• Accurately and efficiently process claims data.
• Review incoming claims to verify all required information is present.
• Select correct member and provider records to process claims appropriately.
• Enter claim details into the computerized processing system.
• Maintain documentation for all processed and pending claims.
• Adjudicate claims according to department policies, relevant state and accreditation standards, and contractual obligations.
• Meet production metrics: average processing of 31 claims per hour with a 98.5% accuracy rate during each pay period.
• Verify scanned paper claims data against quality standards.
• Provide backup support for other claim examiners as necessary.
• Foster cooperation and positive working relationships among colleagues.
• Attend required organizational meetings and comply with company policies.
• Maintain confidentiality for all claim files and related information.
• Perform additional duties as assigned.

Qualifications and Skills

• High school diploma or GED certificate is required.
• Minimum of six months experience in data entry with 10-key and word processing skills, achieving at least 10,000 keystrokes per hour.
• Experience in processing medical claims and familiar with medical billing terminology and coding is strongly preferred.
• Proficiency in Microsoft Office applications.
• Ability to work productively in a work-from-home setting, demonstrating self-discipline to meet production expectations.
• Strong interpersonal abilities to cultivate respectful and cooperative relationships.
• Excellent listening and communication skills to discern critical organizational priorities.
• Capability to organize, prioritize, multi-task, and manage time effectively.
• Accuracy and productivity in dynamic environments with constant interruptions.
• Analytical aptitude to solve problems and handle procedural issues.
• Strict adherence to confidentiality protocols.

Physical and Environmental Requirements

• Primarily sedentary work involving extended periods of sitting.
• Ability to see, hear, speak, and communicate clearly both verbally and in writing.
• Capacity to use telephone, keyboard, and mouse equipment.
• Ability to lift up to 10 pounds when necessary.
• Work is conducted in a home-based remote environment.

Equal Opportunity and Additional Information

American Specialty Health is an Equal Opportunity Employer that prohibits discrimination based on a broad range of protected characteristics, including but not limited to gender, race, religion, disability, and veteran status. Qualified individuals with disabilities are encouraged to request accommodations if needed. The company follows strict policies regarding confidentiality of employee compensation information consistent with federal and state guidelines.