Healthcare Claims Specialist

🕒 May 26

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Evry Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2017

⚕️ Healthcare Insurance

🤝 B2B

🧘 Wellness

Healthcare Insurance • B2B • Wellness

Evry Health is a modern, mobile-first health insurance company that provides fully insured employer health plans and personalized care teams. Built for midsize and larger employers (primarily in Texas), Evry offers no-copay, no-deductible plans, 24/7 virtual care, integrated wellness programs, and individualized support from nurses, nutritionists, and doctors to simplify costs and improve employee health. The company emphasizes a human, member-focused approach and digital tools (iOS/Android app) to deliver care and benefits.

📋 Description

• Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms. • Follows established policies and procedures to pay, pend for additional information, or deny claims. • Process claims subject to Coordination of Benefits (COB) according to plan benefits, COB rules and contractual reimbursement terms. • Accountable to meet and maintain established department production and quality standards. • Create claim test cases, execute, and report on the results. • Identify and communicate defects or claim system issues to those responsible for configuration. • Work with configuration to remediate and retest defects. • Identify and communicate inventory issues to department’s management. • Works with internal departments, vendors, business partners, providers, etc. to help coordinate problem solving in an effective and timely manner. • Develop and maintain desk top procedures related to claim adjudication. • Audit auto-adjudicated and/or manually processed claims. • Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins.

🎯 Requirements

• You have a minimum of 3 years' medical claim adjudication/examination experience, working within a health insurance carrier, health insurance TPA, or equivalent. • You have knowledge of medical and insurance industry terminology including CPT/ICD-10, HCPCS and Revenue Codes. • You possess strong attention to detail and problem-solving skills with a high level of accuracy. • You have experience writing desk top procedures. • You are an excellent communicator, both verbally and in writing. • You can perform comfortably in a fast-paced, deadline-oriented work environment. • You are proficient in Microsoft Office applications Word, Excel, Outlook OneNote, etc. • You have prior experience using a CRM, preferably Salesforce. • You have prior experience with claim testing and or/auditing. • You collaborate and support business and operational units such as Customer Service, Medical Management and Appeals and Grievance. • Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred. • Bonus: Plexis/Quantum Choice experience.

🏖️ Benefits

• Competitive salary • Comprehensive health, dental, and vision insurance as well as life and disability • Retirement savings plan with company match • Generous time off/vacation • Professional development opportunities • Flexible work environment