Claims Examiner

Edison Healthcare, A Relation Company is seeking a Claims Examiner who will be responsible for verifying, adjudicating, and resolving insurance claims. The individual in this role serves clients and providers by ensuring claims are processed accurately, efficiently, and in compliance with company policies and regulatory requirements. The Claims Examiner must demonstrate strong interpersonal, analytical, and organizational skills, and be able to communicate effectively with a variety of stakeholders.

A GLIMPSE INTO YOUR DAY

• Reviews and validates claims for accuracy, completeness, and eligibility based on policy terms and guidelines.
• Analyzes, adjudicates, and resolves claims by approving or denying documentation, calculating benefit amounts, and initiating payments or composing denial letters.
• Ensures legal compliance with company policies, procedures, and applicable state and federal regulations throughout the claims process.
• Maintains accurate records of claims, settlements, denials, and related documentation.
• Addresses questions and concerns from providers, clients, and internal personnel regarding the adjudication process.
• Reports overpayments, underpayments, and irregularities to supervisors.
• Communicates with reinsurance brokers and other stakeholders to obtain necessary information for claim processing.
• Verifies member eligibility, benefit coverage, and authorizations as needed.
• Protects confidential information and ensure HIPAA compliance.
• Participates in process improvement initiatives and update documentation as required.
• Special projects and other duties as assigned.

WHAT SUCCESS LOOKS LIKE IN THIS ROLE

• High school diploma or equivalent required.
• Ability to read, analyze, and interpret company guidelines, benefit documentation, and government regulations.
• Intermediate computer skills, including email, database activity, word processing, and spreadsheets.
• Ability to handle multiple tasks simultaneously and adapt to changing priorities.
• Strong analytical, problem-solving, and communication skills.
• Associate’s degree or technical college coursework preferred.
• 1–3 years of healthcare reimbursement, claims processing, or customer service experience preferred.
• In-depth knowledge of medical coding principles is helpful.
• Familiarity with Medicaid, Medicare, and commercial insurance claims preferred.
• Experience in provider contract development, medical billing/coding, patient accounting, claims auditing, or revenue cycle improvement.