Claims Examiner - TPA

WHO WE ARE

The Claims Examiner is responsible for verifying, adjusting, 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.

• Identifies documentation gaps or discrepancies and coordinates resolution as needed.

• Supports quality, accuracy, and consistency in claims processing through adherence to policies and procedures.

• Effectively utilizes available technology and tools, including emerging and AI‑enabled solutions, to support efficient workflows, accuracy, and a positive client service experience.

• Special projects and other duties as assigned.

WHAT SUCCESS LOOKS LIKE IN THIS ROLE

• High school diploma or equivalent required.

• Minimum 1 year of healthcare reimbursement or claims processing experience.

• 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.

WHY CHOOSE RELATION?

• Competitive pay.

• A safe and healthy work environment provided by our robust benefit program including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays and more.  

• Career advancement and development opportunities.

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Note: The above is not all encompassing of the full position description. 

Relation Insurance Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

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