Health Claim Examiner - HCE SS#01 - NavitsPartners : Job Details

Job Title: Health Claim Examiner (WFH) Rate: $20/HR on W2 Project Duration: 11 Months Location: Remote (New York Licensed - Mandatory)We are inviting applications for the role of Management Trainee - Health Claims Adjudicator (New York Licensed). In this role, you will review, evaluate, and process medical claims submitted by healthcare providers or policyholders to ensure accuracy, compliance with insurance policies, and adherence to New York State regulations.ResponsibilitiesProcess claims and appeals according to standard operating procedures.Validate information entered by indexers.Verify coverage, evaluate eligibility, and determine payment/denial based on policy coverage.Ensure compliance with insurance plan rules, state/federal regulations, and coding guidelines.Maintain documentation on all supplemental claim files and process claims within department standards.Research and interpret policy language and state laws related to submitted claims.Maintain confidentiality of patient information per HIPAA regulations.Detect duplicate claims, overcharges, ineligible charges, contract compliance issues, provider/member fraud, and take corrective actions.Provide email support to troubleshoot and resolve processing issues.Prioritize transactions according to SLA's, ERISA, and state guidelines.Communicate with stakeholders including healthcare providers, policyholders, and internal departments.Support system testing for new features and fixes.Accurately interpret and compile data from multiple sources and systems.Collaborate with onshore/offshore teams and manage own workload to meet team goals.Maintain working files and audit records.Perform basic tasks in MS Excel including MIS reporting.QualificationsMinimum Requirements:Active license with the State of New York to adjudicate health claims.2+ years' experience in supplemental health or group insurance claims operations.Proven experience in employee benefits, supplemental or group health claim adjudication.Preferred Skills:Strong written and verbal communication skills.Analytical and critical thinking skills.High attention to detail and problem-solving ability.Knowledge of healthcare regulations, including HIPAA.Experience with EIS policy administration system (preferred).Strong decision-making skills, ability to work under pressure, and meet deadlines.Proficiency in MS Excel and report generation.Typing speed of 40 WPM.Customer-focused mindset with strong interpersonal skills.Flexibility to work extended hours when needed.