Claims Examiner

About Firstsource

Firstsource Solutions is a leading provider of customized Business Process Management (BPM) services. Firstsource specialises in helping customers stay ahead of the curve through transformational solutions to reimagine business processes and deliver increased efficiency, deeper insights, and superior outcomes. We are trusted brand custodians and long-term partners to 100+ leading brands with presence in the US, UK, Philippines, India and Mexico. Our ‘rightshore’ delivery model offers solutions covering complete customer lifecycle across Healthcare, Telecommunications & Media and Banking, Financial Services & Insurance verticals. Our clientele includes Fortune 500 and FTSE 100 companies. 

Job Title: Claims Examiner-Work From Home

Job Type: Full Time

FLSA Status: Non-Exempt/Hourly

Grade: H

Function/Department: Health Plan and Healthcare Services

Reporting to: Team Lead/Supervisor - Operations

Pay Range: $14.00

Role Description: The Claims Examiner evaluates insurance claims to determine whether their validity and how much compensation should be paid to the policyholder. The Claims Examiner is responsible for reviewing all aspects of the claim, including reviewing policy coverage, damages, and supporting documentation provided by the policyholder

Core Skill Set

 1. Health Insurance Knowledge

• Understanding of medical insurance policies (HMO, PPO, EPO, etc.).
• Knowledge of benefits eligibility covered services, and policy exclusions.
• Familiarity with coordination of benefits (COB) and subrogation.

2. Claims Adjudication Expertise

• Ability to evaluate and process various types of claims (inpatient, outpatient, pharmacy, etc.).
• Adjudication rules application based on policy provisions.
• Understanding of EOBs (Explanation of Benefits) and how to interpret them.

3. Medical Terminology & Coding

• Familiarity with ICD-10, CPT, and HCPCS codes.
• Ability to review and interpret medical records and provider billing statements.

4. Regulatory Compliance

• Knowledge of HIPAA and HITECH laws.
• Understanding of state and federal healthcare regulations (e.g., ACA, Medicare/Medicaid guidelines).

Technical & Analytical Skills

• Claims processing systems (e.g., Facets, QNXT, Nasco, etc).
• Strong data analysis skills to detect discrepancies or errors in claims.

Communication & Customer Service

• Strong verbal and/or written communication to clarify decisions and respond to provider/member inquiries.
• Ability to explain complex insurance terms in plain language.

Attention to Detail & Time Management

• High accuracy in reviewing detailed claims data.
• Ability to manage multiple claims or inquiries within strict turnaround times (TATs) and performance metrics.

Ethical Judgment & Confidentiality

• Discretion in handling sensitive health and personal information.
• Ethical approach to fair and unbiased adjudication decisions.

Additional Qualifications

• Ability to download 2-factor authentication application(s) on personal device, in accordance with company and/or client requirements

• Ability to pass the required pre-employment background investigation, including but not limited to, criminal history, work authorization verification and drug test 

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

This position work remotely from home. 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must be able to regularly or frequently talk and hear, sit for prolonged periods, use hands and fingers to type, and use close vision to view and read from a computer screen and/or electronic device. Must be able to occasionally stand and walk, climb stairs, and lift equipment up to 25 pounds. 

Firstsource is an Equal Employment Opportunity employer. All employment decisions are based on valid job requirements, without regard to race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, age, disability, genetic information, veteran status, or any other characteristic protected under federal, state or local law.

Firstsource also takes Affirmative Action to ensure that minority group individuals, females, protected veterans, and qualified disabled persons are introduced into our workforce and considered for employment and advancement opportunities