Claims Examiner

Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market to do more for clients and take them beyond the standard Point A to Point B. We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as network and payment integrity pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.

Point C is looking for a detail-oriented and motivated Claims Examinerto join our this role youll be responsible for accurately processing medical claims while ensuring compliance with plan documents policies and industry regulations. The ideal candidate is analytical organized and experienced in self-funded or third-party administration environments.

Primary Responsibilities:

• Adjudicatenew claims and process adjustments including denials upon receipt ofadditionalinformation
• Review and resolve appeals and subrogation/third-party liability cases
• Manage individual inventory to ensuretimelyturnaround and production goals are met
• Ensure claims are processedin accordance withstop loss contract terms
• Respond to internal and external inquiries via email and other channels within establishedtimeframes
• Follow up on missing or incomplete information to ensure claims can be accurately processed
• Maintain minimum production financial and procedural accuracy standardson a monthly basis

Qualifications:

• Experience with Third Party Administrator (TPA) or self-funded claims administration preferred
• 1-2 years of experience in insurance claims processing required
• Experience reviewing and finalizing claim payments for accuracy in accordance with plan policies
• Ability to interpret and apply plan documents to ensure accurate claims adjudication
• Experience with VBA systems preferred
• Working knowledge of CPT and ICD-10 coding
• Basic understanding of medical terminology
• Strong communication and customer service skills
• Proficiency in Microsoft Office and general computer applications
• Ability to maintain confidentiality and comply with all company policies and procedures
• Able to work independently with minimal supervision
• Ability to prioritize multitask and work overtime as needed
• Associate Degree Preferred

• Comprehensive medical dental vision and life insurance coverage
• 401(k) retirement plan with employer match
• Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
• Paid time off (PTO) and disability leave
• Employee Assistance Program (EAP)

Equal Employment Opportunity: At Point C Health we know we are better together. We value respect and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our businessand our societystronger. Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices including selection hiring performance management promotion transfer compensation benefits education training social and recreational activities to all persons regardless of race religious creed color national origin ancestry physical disability mental disability genetic information pregnancy marital status sex gender gender identity gender expression age sexual orientation and military and veteran status or any other protected status protected by local state or federal law.