Health Plan Claims Examiner

Job Description

Location: Remote (US-based)

We are seeking a Health Plan Claims Examiner to adjudicate medical and pharmacy claims accurately, on time, and in compliance with plan benefits and applicable regulations for a shared services center. This position is a full-time, direct hire opportunity available on a fully remote basis within the U.S. The role applies a range of reimbursement methodologies, resolves coordination of benefits and complex claim inquiries, and helps ensure every provider is paid correctly for the care they deliver.

This role is well aligned for an experienced claims professional who takes pride in accuracy and enjoys detailed, high volume work with real financial impact. The ideal candidate works confidently with a high degree of autonomy from a remote home office, manages their own claims queue against daily production targets, and stays current on the rules that guide every claims decision.

Responsibilities:

• Adjudicate medical, surgical, and ancillary claims against plan benefits and contract terms
• Apply correct reimbursement methodologies, including fee schedule, DRG, per diem, and percentage of charge
• Identify and resolve coordination of benefits, subrogation, and third-party liability situations
• Process claim adjustments, voids, and reprocessing requests within established turnaround standards
• Research and resolve provider disputes, member appeals, and complex claim inquiries
• Identify potential fraud, waste, and abuse patterns and refer them to special investigations
• Maintain claims processing accuracy at or above the 97% quality benchmark
• Stay current with CMS regulations, state mandates, and payer specific claims processing rules
• Process out-of-network claims, including reasonable and customary determinations and member balance calculations

Qualifications:

• High school diploma required; associate degree in healthcare or business preferred
• Minimum of 2 years of medical claims adjudication experience in a health plan or TPA environment
• Experience with claims processing platforms such as Facets, QNXT, HealthEdge, or similar
• Knowledge of CPT, ICD-10, HCPCS, revenue codes, and standard reimbursement methodologies
• Understanding of COB rules, Medicare Secondary Payer regulations, and state insurance mandates
• Strong analytical skills with consistent attention to detail while meeting production goals

Schedule:

• Full-time position
• Fully remote within the U.S.
• Monday through Friday, standard business hours ([Time Zone])
• 40 hours per week

Salary Range: The salary range for this position is approximately $46,000 – $66,000 annually ($22.12 – $31.73 per hour), based on experience and qualifications.

Interview Process: Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.