Claims Examiner

About The Role
Brighton Health Plan Solutions (BHPS) is seeking an experienced Healthcare Claims Examiner skilled in the interpretation of Hospital and Ancillary contracts, Medical Policies and Payment procedures as well as capable of manually processing claims according to all outlined Policies and Procedures.
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.

Primary Responsibilities

• Research and document pertinent information on claims requiring adjudication. Apply medical policy, contractual provisions, and operational procedures to ensure accurate adjudication and/or adjustment.
• Reprice Workers’ Comp and No-Fault claims while adhering to the specified turnaround times.
• Perform quality review of claims and logic changes/updates in Impact.
• Authorizes generation of letters/questionnaires, etc. to customers and providers to obtain additional information; may initiate telephone inquiries.
• Assist Customer Service in responding to and resolving customer questions and concerns.
• Conduct research and address client inquiries.
• Perform client requested claim adjustments; provide clear and concise written responses to each client inquiry within the specified timeframes.

Essential Qualifications

• Knowledge of contracts, medical terminology, and claims processing and procedures.
• 1+ year computer medical billing or claims adjudication systems experience.
• Excellent written and oral communication, interpersonal and negotiation skills with a demonstrated ability to prioritize tasks as required.
• Ability to meet expected production and quality standards.
• Proficient in Microsoft Office Suite- specifically Microsoft Word and Microsoft Excel.
• Ability to maintain a professional demeanor under pressure.
• Capable of managing multiple complex issues.
• High School Diploma or GED diploma; some college or business school education is a plus.

About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.
Come be a part of the Brightest Ideas in Healthcare™.

Company Mission
Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement
At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities. We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace. We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.
*We are an Equal Opportunity Employer