Claims Examiner II

MagnaCare•Las Vegas, NV

13d

About The Position

The Claims Examiner II is responsible for reviewing and adjudicating claims submitted for reimbursement that fall outside auto adjudication standards. This role ensures compliance with quality, productivity, and timeliness requirements by applying medical policies, contractual provisions, and operational procedures. The Claims Examiner II will generate correspondence, collaborate with Customer Service, research and resolve client inquiries and escalations, and perform in-depth research on account receivables. This position requires adaptability and willingness to provide backup support across various departments and roles, processing all claim types including Professional and Facility claims, and performing claim adjustments as needed.

Requirements

Strong knowledge of healthcare contracts, medical terminology, and claims processing procedures.
Prior experience processing claims is required.
Minimum 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 with 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 on a daily basis, ensuring compliance with quality, productivity, and timeliness requirements.
Apply medical policies, contractual provisions, and operational procedures to ensure precise adjudication and adjustments.
Generate correspondence, such as letters and questionnaires, to gather additional information from customers and providers; may also initiate phone inquiries.
Collaborate with Customer Service to address and resolve customer inquiries and concerns effectively.
Research and resolve client inquiries and escalations in a timely manner, collaborating with internal teams as needed to ensure effective resolution.
Execute client-requested claim adjustments and provide clear, concise written responses to client inquiries within established deadlines.
Perform in-depth research on account receivables and spreadsheets that require claim adjustments, delivering thorough and clarifying responses to providers and clients.
Be adaptable and willing to provide backup support across various departments and roles as needed.
Process all claim types including Professional and Facility claims.
Perform Claim Adjustments as needed.
Execute client-requested claim research and adjustments and provide clear, concise written responses to client inquiries within established deadlines.