Claims Examiner

Point C, a National third-party administrator (TPA) specializing in self-funded benefit programs, is seeking a detail-oriented and motivated Claims Examiner to join their team. This role involves 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:

• Adjudicate new claims and process adjustments, including denials upon receipt of additional information
• Review and resolve appeals and subrogation/third-party liability cases
• Manage individual inventory to ensure timely turnaround and production goals are met
• Ensure claims are processed in accordance with stop loss contract terms
• Respond to internal and external inquiries via email and other channels within established timeframes
• Follow up on missing or incomplete information to ensure claims can be accurately processed
• Maintain minimum production, financial, and procedural accuracy standards on a monthly basis

Qualifications:

• Experience with Third Party Administrator (TPA) or self-funded claims administration preferred
• At least 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
• Demonstrated understanding of both claim review processes and underlying benefit plan design
• Experience with HealthPac, El Dorado, Javelina, or 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