Claim Examiner II

Solis Health Plans• Doral, FL, US, FL

31d•Onsite

About The Position

The Claims Examiner II is responsible for the accurate and timely adjudication of complex healthcare claims within a managed care environment, with a focus on Dual Eligible Special Needs Plans (DSNP) and Medicare lines of business. This role involves advanced application of benefit plans, policies, and regulatory guidelines to ensure proper claim processing, including new claims, reprocessed claims, overturned disputes, and appeals. The Claims Examiner II serves as a subject matter resource to team members, supports quality and compliance initiatives, and plays a key role in ensuring payment accuracy and enhancing member and provider satisfaction.

Requirements

High school diploma or equivalent; associate or bachelor’s degree preferred.
Minimum of 4–6 years of claims processing experience in a managed care or health insurance environment.
Strong knowledge of Medicare and DSNP claims processing guidelines, including benefit application and coordination of benefits (COB).
Experience handling claims reprocessing, disputes, and appeals (including overturned cases).
Familiarity with CPT, HCPCS, and ICD-10 coding.
Understanding of provider contracts and reimbursement methodologies.
Strong analytical and problem-solving skills with high attention to detail.
Ability to manage multiple priorities in a fast-paced environment.
Proficiency in claims processing systems and Microsoft Office applications.

Nice To Haves

Knowledge of CMS regulations and audit requirements.
Prior experience working with dual-eligible populations.
Medicare, Part C claims processing experience.

Responsibilities

Review, analyze, and process complex medical claims in accordance with Medicare and DSNP benefit structures, policies, and procedures.
Process Institutional and Professional Claims, ensuring accurate application of benefits, coding, and reimbursement methodologies.
Accurately adjudicate new day claims, ensuring proper application of benefits, coding edits, and pricing methodologies.
Handle higher-complexity claims, including those requiring detailed research, manual pricing, or exception handling.
Evaluate and process claim disputes and reconsiderations, including those that result in overturn decisions requiring correction and re-adjudication.
Handle appeals-related claim adjustments, ensuring timely and accurate implementation of appeal outcomes.
Interpret provider contracts, fee schedules, and reimbursement methodologies to ensure correct payment.
Ensure compliance with CMS (Centers for Medicare & Medicaid Services), state regulations, and internal policies.
Identify, investigate, and resolve complex claim issues, system errors, and potential compliance risks; escalate as needed.
Serve as a resource for Claims Examiner I staff by providing guidance, answering questions, and assisting with issue resolution.
Participate in audits, quality reviews, and contribute to corrective action plans as needed.
Maintain higher productivity and quality standards, consistently meeting or exceeding turnaround time requirements.
Document claim processing activities clearly and accurately in system notes.
Collaborate with internal departments such as Provider Relations, Appeals & Grievances, and Configuration teams to resolve claim issues and improve processes.