Claims Examiner I

MagnaCare • Las Vegas, NV

8d

About The Position

The Claims Examiner I reviews and adjudicates reimbursement claims that fall outside auto-adjudication standards, applying medical policies, contractual provisions, and operational procedures. The role handles claim adjustments, researches account receivables and client inquiries, and communicates with customers, providers, and internal teams to resolve issues accurately and within established deadlines. The examiner is also expected to provide backup support across departments and roles as needed.

Requirements

• Strong knowledge of healthcare contracts, medical terminology, and claims processing procedures.
• Prior experience processing claims.
• At least 1 year of experience in medical billing, claims adjudication, or a related role.
• Excellent written and verbal communication skills, with the ability to manage inquiries professionally and efficiently.
• Strong analytical skills and the ability to research and resolve complex claim issues.
• Proficiency in Microsoft Office Suite, particularly Microsoft Word and Excel.
• Ability to meet production and quality standards while managing multiple priorities.
• Strong problem-solving skills and the ability to maintain professionalism under pressure.

Responsibilities

• Review and adjudicate claims submitted for reimbursement that fall outside auto-adjudication standards, meeting quality, productivity, and timeliness requirements.
• Apply medical policies, contractual provisions, and operational procedures to adjudicate claims and make adjustments accurately.
• Generate correspondence, including letters and questionnaires, to gather additional information from customers and providers, and initiate phone inquiries when needed.
• Collaborate with Customer Service to address and resolve customer inquiries and concerns.
• Research and resolve client inquiries and escalations promptly, collaborating with internal teams as needed.
• Execute client-requested claim adjustments and provide clear, concise written responses to client inquiries within established deadlines.
• Research account receivables and spreadsheets requiring claim adjustments, and provide thorough, clarifying responses to providers and clients.
• Provide backup support across various departments and roles as needed.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed