Claims Examiner II

Doctors Healthcare Plans • Coral Gables, FL

8d

About The Position

The Claims Examiner is responsible for providing expertise and claims support by reviewing, researching, investigating, processing, and adjusting claims, along with other duties as necessary. The role reviews, researches, analyzes, and processes professional claims using multiple applications and platforms, and ensures the appropriate benefits are applied using relevant tools and guidelines. The examiner communicates with internal departments, keeps current with system updates and new applications through training, and meets established quality and production performance goals.

The description outlines the general type and level of work and responsibilities, which are not necessarily all-inclusive or specific to an individual team member. No third-party agencies or submissions will be accepted. The company states that it is committed to a diverse environment and provides equal consideration to qualified applicants without regard to protected characteristics. The posting does not create an employment contract, and information may change without notice.

Requirements

• High school diploma or GED.
• Excellent oral and written communication skills.
• 1–3 years of health claims processing experience.
• Working knowledge of COB and MSP; medical terminology is preferred.
• Computer literacy.
• Knowledge of current Medicare Advantage operational and regulatory guidelines established by CMS, AHCA, and other federal and state regulatory guidelines.
• Excellent organizational skills.
• Ability to work well under pressure and in difficult situations.

Nice To Haves

• Knowledge of medical terminology.

Responsibilities

• Review, research, analyze, and process professional claims using multiple applications and platforms accurately.
• Ensure the proper benefits are applied to claims using appropriate tools, such as CMS guidelines.
• Communicate with internal departments using clear, simple language to ensure understanding.
• Keep current through training on system updates and new applications.
• Meet and maintain established performance goals for quality and production.
• Perform other duties as necessary.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED