Claims Examiner II

Do you wake up every morning inspired to solve problems and make a meaningful impact in healthcare? If so, we want to hear from you. 

At Innovista Health, we're leading the effort to drive transformative change in healthcare. We are a full-service value-based care and managed service organization that partners with independent providers to help them navigate, succeed, and thrive in value-based care. 

Founded in 2013, Innovista Health offers solutions for providers at every point along the continuum of value-based care, ranging from care management, provider/ACO enablement, and quality improvement to performance insights, reporting, and managed administrative/payment services? 

While Innovista Health’s main offices are in Oak Brook, IL and Houston, TX, we have remote employees throughout the US. 

 This fully remote role offers the chance to be part of our exciting journey towards a better, more efficient healthcare system. 

 Job Summary

The Claims Examiner II is responsible for the detailed analysis of claims, making informed decisions on payment approvals or denials, and providing expertise on claims processing matters to both colleagues and management. This role involves serving as the claims lead for specific clients, performing advanced claim functionalities, and actively contributing to the resolution of provider and member issues.? 

Essential Duties 

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position. 

• Act as the claims lead for one or more clients, as required.? 
• Perform advanced claim functionalities, including PDC, 095, 5Z, and appeals claims processing.? 
• Approve or deny claims for payment, ensuring correctness, proper authorizations, and resolution of system hold codes.? 
• Identify and resolve recurring provider or member issues by analyzing trends and recommending solutions to management.? 
• Coordinate payments between insurance companies to capture COB savings in cases involving multiple insurers.? 
• Research and resolve claims issues received from the Customer Services department in a timely manner.? 
• Recommend improvements to workflow processes and organizational structure to enhance department productivity.? 
• Provide feedback to the department manager on Standard Operating Procedures for completeness and accuracy.? 
• Contribute to team goals and results as determined by the Claim Manager.? 
• Maintain member/patient privacy in accordance with HIPAA standards.? 
• Perform other duties as assigned.? 

•  Associate’s degree or equivalent experience required.? 
• 2-3 years of relevant professional experience, including claims processing.? 
• Knowledge of claims and processes in Commercial, Medicare, and Medicaid health plan/TPA organizations.? 
• Extensive knowledge of CPT-4, HCPCS, and ICD-10 coding.? 
• Familiarity with medical terminology.? 
• Excellent organizational skills.? 
• Effective verbal and written communication skills.  
• Analytic skills for problem-solving.? 
• Proficient in MS Office Applications and ability to learn department and job-specific software systems.? 
• High attention to detail and a high degree of accuracy.  
• Commitment to Innovista’s corporate mission and values.? 

BENEFITS: 

We are committed to creating a culture where everyone feels important, welcomed, and included. We demonstrate this commitment by offering a comprehensive benefits package that fosters opportunities for growth and advancement and supports the physical, mental, and financial wellbeing of our team members. 

HEALTH & WELLBEING 

• A choice health coverage, including HMO and PPO, plus Flexible Spending Account (FSA) and Health Savings Account (HSA) options 
• Dental and vision coverage 
• Company-paid benefits (short- and long-term disability, employee life, and accidental death and dismemberment) 
• Employee Assistance Program 
• Bereavement Leave (full time employees for the loss of an immediate family member)  
• Paid Military Leave Benefits  
• Discounts and perks on gym memberships, shopping, travel, recreation, and more 

FINANCIAL GROWTH 

• A yearly discretionary bonus 
• 401(k) with a company match 
• Credit Union Banking alternative  
• Wellness Rewards with Monetary Incentives  
• Rewarding employee referral bonuses 

WORK/LIFE BALANCE 

• Flexible schedule and work from home options for numerous roles  
• Nine paid company holidays + Sick and Wellness Days + accrued PTO  
• Commuter benefits  
• Paid Parental Leave (up to 6 weeks, subject to applicable waiting period) 

JOB SATISFACTION & ADVANCEMENT 

• Clear career advancement and growth pathways 
• Continuous education opportunities and financial reimbursement (mileage and certifications. This varies based on leadership and relevance to job) 
• Diversity, Equity & Inclusion Committee with various Business Resource Groups you can join 
• Company-wide socials and gatherings 
• "Dress for Your Day" policy 

Benefits may be subjected to an applicable waiting period.