Claims Examiner II

DOCTORS HEALTHCARE PLANS, INC. • Coral Gables, FL

9d

About The Position

The Claims Examiner is responsible for providing expertise and claims support by reviewing, researching, investigating, processing, and adjusting claims, along with performing other duties as necessary. The role reviews and processes professional claims using multiple applications and platforms, applies appropriate benefits using tools such as CMS guidelines, and communicates with internal departments. The examiner keeps current with system updates and new applications through training and maintains established quality and production goals.

This description outlines the general type and level of work and responsibilities; the duties are not all-inclusive or necessarily specific to any individual team member. No third-party agencies or submissions will be accepted. The company states that it is committed to a diverse environment and that qualified applicants will receive consideration without regard to protected characteristics. The posting also notes that it does not create an employment contract and that information and applicant suitability may be determined or changed at the company's or its clients' discretion.

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, preferably.
• Knowledge of medical terminology.
• 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

• Working knowledge of COB and MSP is preferred.

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 up with system updates and new applications through training.
• Meet and maintain established performance goals for quality and production.

What This Job Offers

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