Healthcare Claims Processor

Claims Processor / Claims Examiner - Healthcare

Location: New York, NY, 10004 (Hybrid)

Rate: $30 to $32/hr on W2

Hours: 35 hours/week

Position Overview

This position is responsible for the data entry and system adjudication of provider claims. The incumbent will review and process medical and surgical claims and authorize the final disposition of claims in accordance with established guidelines, ensuring accuracy and timely processing.

Key Responsibilities

• Process claims involving medical and/or surgical services while screening for complete member and provider information.
• Apply administrative policies and procedures using established claims processing manuals.
• Authorize the generation of letters and questionnaires to providers when additional information is required.
• Review descriptions of services on claims to determine the validity of charges and identify potential errors.
• Evaluate and examine claims pended by the system due to contractual and/or payment discrepancies.
• Review claims for accuracy, completeness, and compliance with applicable processing guidelines.
• Identify and resolve errors or discrepancies during the claims review process.
• Maintain established departmental production and quality goals.
• Maintain accurate individual production counts.
• Update claims processing manuals and reference materials as required.
• Attend refresher training seminars and remain current with claims processing procedures and guidelines.
• Perform other related duties as assigned.

Required Education, Training & Professional Experience

• Associate's degree or an equivalent combination of education and relevant experience.
• Minimum 2 years of experience in the healthcare insurance industry.
• Minimum 2 years of experience with integrated claims processing.
• Proficient data entry skills with strong attention to detail.
• Thorough knowledge of medical terminology.
• Working knowledge of CPT, ICD, and Revenue Codes.
• Experience processing and reviewing healthcare provider claims.
• Ability to identify claim errors, discrepancies, and invalid charges.
• Strong analytical, decision-making, and problem-solving skills.
• Ability to work accurately while meeting established productivity and quality standards.

Preferred Skills

• Experience with medical and surgical claims processing.
• Experience reviewing system-pended claims.

Pride-Health offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, pet insurance and employee discounts with preferred vendors.

Equal Employment Opportunity

Pride-Health is an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment

Pride-Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.

Only applicable for San Francisco Candidates: Under the San Francisco Lactation in the Workplace Ordinance, we will provide written notice of lactation accommodation rights, and this notice will automatically be given upon hiring, any inquiry of parental leave or lactation accommodation.

Only applicable for Kentucky positions: For this type of employment, state law requires a criminal record check as a condition of employment. This applies to direct care staff (Examples: RN, LPN, Nurse Aides, Therapists) referred to Kentucky nursing facilities, assisted living communities, or long-term care facilities, in accordance with KRS 216.793.

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