Claims Examiner

Responsible for the oversight and timely/accurate claims adjudication for all clients assigned. Claim types would include but may not be limited to data entry, dental, professional and/or institutional.

Must maintain a minimum of three consecutive months of production, quality and attendance after completing training in order to be eligible for a Claims Examiner II position. This is a remote work position.

• Responsible for accurately processing EDI Errors. 
• Processing the different claims types to include Institutional, Professional and Dental Claims.
• Review, research, and resolve claims in accordance with contracts and policies through the utilization of reference materials and on-line tools.  
• Consistently maintains department minimum productivity and quality standards for adjudicating claims while maintaining established accuracy guidelines. 
• Must comply with strict privacy, integrity, confidentiality, availability and maintenance of Protected Health Information.
• Provide feedback to the unit Manager regarding plan benefits, Benefit Quoting Tool (BQT) and system issues.
• Processing all levels of claims procedures to include: Action Requests, Correspondence, Audit and Quality (AQ) work items and claim adjustments. 
• Consistently maintains department minimum productivity and quality standards for adjudicating claims while maintaining established accuracy guidelines. 
• Other projects as assigned.

• High School Diploma or equivalent
• Basic computer skills/ Word processing/ Windows operative system and Google Workspace experience preferred.
• 1-2 years healthcare industry experience 
• CPT, ICD-10, & HCPCS proficiency

• Sight within normal ranges, with or without use of corrective lenses.
• Finger dexterity. 
• Ability to be stationary for long periods of time.
• Ability to lift 10 to 15 pounds

Access to PHI:

• Routine & re-occurring access to all forms of PHI – The duties of the position require regular and unrestricted contact with PHI.
• Routine and limited and does not require manager approval - The duties of the position require routine contact with a limited set of PHI that does not require manager approval. Examples include claims adjudication. 
• Restricted and limited to manager approval on an as needed basis – Access to PHI is flexible and limited to a need to know basis pre-determined by the manager/supervisor depending on the nature of the task to be performed by this position. 
• Subject to incidental PHI disclosure – The position will at times come in contact with PHI that cannot be prevented, is limited in nature, and that occurs as a result of another permitted use or disclosure.  Examples include proximity to areas where PHI is accessed or discussed.  
• No PHI is accessed to perform the duties of the position – The position without exception has no job requirements involving the access to PHI.

BENEFITS:
FCH offers comprehensive benefits focused on supporting employee health, financial security, and work-life balance.

• Health & Insurance: Medical (HSA and PPO plans) and Vision coverage, Dental plan, employer-provided Life Insurance, and Short- & Long-Term Disability coverage.
• Financial & Retirement: Health Savings Account (HSA) with company contributions, Flexible Spending Account (FSA), 401(k) plan with an employer match, and discretionary Profit Sharing.
• Time Off & Development: Paid Time Off (PTO) accrued based on tenure, Paid Holidays, community service, and Tuition Reimbursement for continuing education.
• Support: Employee Assistance Program (EAP) for confidential professional counseling, and a Wellness program with rewards.

Note: Benefits are subject to change with or without notice.

Routine and limited and does not require manager approval - The duties of the position require routine contact with a limited set of PHI that does not require manager approval. Examples include claims adjudication.

For California employees, please review Privacy Act: https://www.fchn.com/documents/fch/pdf/caprivacynoticeemployeesandapplicantsfina