Claims Examiner - Kentucky

Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for clients – and take them beyond the standard “Point A to Point B.” We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.Point C is looking for a detail-oriented and motivated Claims Examiner to join our team. In this role, you’ll be responsible for accurately processing medical claims while ensuring compliance with plan documents, policies, and industry regulations. The ideal candidate is analytical, organized, and experienced in self-funded or third-party administration environments.Primary ResponsibilitiesAdjudicate new claims and process adjustments, including denials upon receipt of additional informationReview and resolve appeals and subrogation/third-party liability casesManage individual inventory to ensure timely turnaround and production goals are metEnsure claims are processed in accordance with stop loss contract termsRespond to internal and external inquiries via email and other channels within established timeframesFollow up on missing or incomplete information to ensure claims can be accurately processedMaintain minimum production, financial, and procedural accuracy standards on a monthly basisQualificationsAssociate's degree preferredExperience with Third Party Administrator (TPA) or self-funded claims administration preferredAt least 2+ years of experience in insurance claims processing requiredExperience reviewing and finalizing claim payments for accuracy in accordance with plan policiesAbility to interpret and apply plan documents to ensure accurate claims adjudicationDemonstrated understanding of both claim review processes and underlying benefit plan designExperience with HealthPac, El Dorado, Javelina, or VBA systems preferredWorking knowledge of CPT and ICD-10 codingBasic understanding of medical terminologyStrong communication and customer service skillsProficiency in Microsoft Office and general computer applicationsAbility to maintain confidentiality and comply with all company policies and proceduresAble to work independently with minimal supervisionAbility to prioritize, multitask, and work overtime as neededIndividual compensation will be commensurate with the candidate's experience and qualifications. Certain roles may be eligible for additional compensation, including bonuses, and merit increases. Additionally, certain roles have the opportunity to receive sales commissions that are based on the terms of the sales commission plan applicable to the role.Pay Transparency$18—$22 USDBenefitsComprehensive medical, dental, vision, and life insurance coverage401(k) retirement plan with employer matchHealth Savings Account (HSA) & Flexible Spending Accounts (FSAs)Paid time off (PTO) and disability leave Employee Assistance Program (EAP)Equal Employment Opportunity: At Point C Health, we know we are better together. We value, respect, and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our business—and our society—stronger. Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.