Claims Examiner

Summary Location : 1 Monarch Place; Springfield MA Schedule : Monday-Friday; 8hrs per day; Flexible start time 7a-630pm The Claims Examiner is responsible for providing claims production to the Claims Production Team to enable the administration of non-auto adjudicated claims which contributes to the overall success of Claims Production ensuring specific individual goals, plans, initiatives are executed and delivered in support of the teamu2019s business strategies and objectives. The Claims Examiner is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New Englandu2019s entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New Englandu2019s Code of Conduct. Accountabilities u2022 Champions a customer focused culture to deepen client relationships and leverage broader Health New Englandu2019s relationships, systems and knowledge. u2022 Understand how Health New Englandu2019s culture and the CX Promise should be considered in day-to-day activities and decisions. u2022 Actively pursues effective and efficient operations of their respective areas in accordance with Health New Englandu2019s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct. u2022 Champions a high-performance environment and contributes to an inclusive work environment. u2022 Contributes to overall Claims Production productivity by accurately adjudicating claims at all levels of complexity. u2022 Meets/exceeds individual, role, and departmental standards of quality and productivity. u2022 Finalizes claims to correct processing discrepancies and other edits by reviewing all available information and applying documented policies and procedures. u2022 Resolves specialty pends to remedy processing discrepancies and other edits while coordinating editing from external Claims Adjudication Partners/vendors. u2022 Evaluates claims to ensure payments are reasonable for the services rendered. u2022 Identifies discrepancies and/or gaps in auto adjudication, documented policies and procedures to Senior Examiners. u2022 Identifies unexplained variations in claims adjudication to Senior Examiners. High School diploma with a minimum of 3 years of progressively responsible health care claims insurance administration experience or an equivalent combination of education and experience. u2022 Knowledge and understanding of health care payer industry standards; Experienced in healthcare related standards such as HIPAA, ACA, CMS, AMA, DOI, MassHealth, ERISA and other regulatory agencies u2022 Healthcare knowledge of industry coding standards/forms including by not limited to CPT4, ICD10, UB04, and HCF1500. u2022 Experience with health claims processing systems and related technology. u2022 Experience in handling confidential information. u2022 Excellent interpersonal skills; Demonstrated ability to work with teams. u2022 Excellent oral and written communication and interpersonal skills. u2022 Proficiency with Microsoft Office products. Education: GED or HiSET (Required) Certifications: Compensation Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees. Minimum - Midpoint - Maximum $23.46 - $26.97 - $31.91 Equal Employment Opportunity Employer Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

Created: 2026-04-01