Claims Examiner

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🔥 8 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

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Wellcove

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1989

🛡️ Insurance

🏥 Healthcare

☁️ SaaS

Insurance • Healthcare • SaaS

Wellcove is a third‑party administrator (TPA) focused on the senior market and long‑term care (LTC) benefits. Its cloud‑native LTC Now platform and AssuriCare services provide automated claim administration, eligibility determination, auto‑adjudication, payment processing, digital care management, provider matching, risk evaluation/analytics, and business process outsourcing for carriers, state retirement plans, and reinsurers. The company emphasizes automation, payment integrity, and tailored administrative solutions for long‑term care and Medicare supplement administration.

📋 Description

• Manage and handle all Outbound calls and adjudicate claims. • Adjudicating HP/AD claims. • Handling all Outbound calls. • Should be able to prioritize work and adjudicate claims as per turnaround time. • Job involves working independently on researching, reviewing, summarizing, and recommending a course of action on claims where an appeal or a grievance has been filed for a denied / under payment. • To ensure claims are adjudicated as per the client/company guidelines. Provide continual evaluation of processes and procedures. • To respond to and resolves claims received via emails. • Candidate should be able to correctly calculate claim amounts for the customers. • Complying with company regulations regarding HIPAA, confidentiality, and private health information.

🎯 Requirements

• Should have knowledge of medical terminology, human anatomy with basic math knowledge of calculating simple interest, compound interest. • Should have excellent problem-solving skills with an eye for detail, to be able to do root cause analysis of complex claims. • Should have a positive approach and open to learning process dynamics. • Ready to handle work pressure and ensure deliverables within timelines. • Experience in handling US HIP claims. • Should have knowledge of ICD 10, CPT, Surgery procedures, Revenue codes, medical terminology, medical documents, Inpatient vs Outpatient claims etc. • Should have some experience in reading and comprehending medical documents.

🏖️ Benefits

• Collaborative team spirit. • Accountable and able to work remotely and independently. • Able to pass background screening and drug tests pre and post hire – includes THC • Verification of high school, GED, or college diploma upon request. • Timely responses from three professional references. • Able to provide a dedicated remote work location free from background noises, interruptions, and desk clutter. • Able to provide an ongoing reliable internet connection and access to a smart phone for Multi Factor Authentication and communication purposes.