Claims Examiner

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 Responsibilities:

• Adjudicate new claims and process adjustments, including denials upon receipt of additional information
• Review and resolve appeals and subrogation/third-party liability cases
• Manage individual inventory to ensure timely turnaround and production goals are met
• Ensure claims are processed in accordance with stop loss contract terms
• Respond to internal and external inquiries via email and other channels within established timeframes
• Follow up on missing or incomplete information to ensure claims can be accurately processed
• Maintain minimum production, financial, and procedural accuracy standards on a monthly basis

Qualifications:

• Experience with Third Party Administrator (TPA) or self-funded claims administration preferred
• At least 2+ years of experience in insurance claims processing required
• Experience reviewing and finalizing claim payments for accuracy in accordance with plan policies
• Ability to interpret and apply plan documents to ensure accurate claims adjudication
• Demonstrated understanding of both claim review processes and underlying benefit plan design
• Experience with HealthPac, El Dorado, Javelina, or VBA systems preferred
• Working knowledge of CPT and ICD-10 coding
• Basic understanding of medical terminology
• Strong communication and customer service skills
• Proficiency in Microsoft Office and general computer applications
• Ability to maintain confidentiality and comply with all company policies and procedures
• Able to work independently with minimal supervision
• Ability to prioritize, multitask, and work overtime as needed
• Associate Degree Preferred

Individual 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$19—$22 USDBenefits:

• Comprehensive medical, dental, vision, and life insurance coverage
• 401(k) retirement plan with employer match
• Health 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.