Medical Claims Specialist – Remote WV

Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development. 

Summary

The Claims Examiner is responsible for reviewing, evaluating, and processing claims in accordance with policy provisions, regulatory requirements, and organizational guidelines. This role ensures timely, accurate, and fair adjudication of claims while maintaining a high level of customer service and compliance.

Your role in our mission

• Review and analyze claim submissions, supporting documentation, and policy details.

• Determine claim eligibility, coverage, and benefits according to company policies and industry regulations.

• Request additional documentation or information as needed to finalize claim determinations.

• Accurately calculate payment amounts and authorize claim settlements.

• Maintain detailed, organized claim files and records in the claims management system.

• Communicate claim decisions clearly to policyholders, providers, or other stakeholders.

• Collaborate with internal departments (e.g., underwriting, legal, provider relations) for complex claim cases.

• Identify potential fraud, waste, or abuse and escalate cases as required.

• Ensure all claims are processed within required timelines and service-level agreements.

• Stay up to date on industry regulations, policy changes, and best practices.

What we’re looking for

• High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred.

• 2+ years of claims processing or insurance industry experience preferred.

• Strong knowledge of claims adjudication procedures, policies, and regulatory requirements.

• Excellent analytical, problem-solving, and decision-making skills.

• Strong attention to detail and accuracy.

• Proficient in claims management software and Microsoft Office Suite.

• Effective written and verbal communication skills.

What you should expect in this role

• Analytical thinking

• Decision quality

• Time management

• Compliance awareness

• Customer focus

• Remote position

The pay range for this position is $28,500.00 – $40,700.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.