Claims Examiner III

DOCTORS HEALTHCARE PLANS, INC. • Coral Gables, FL

6d

About The Position

The Claims Examiner III is a senior-level claims professional responsible for the accurate and timely adjudication of complex professional and institutional claims in accordance with regulatory requirements, contractual agreements, and internal policies. This role supports departmental workflow oversight, assists leadership with productivity and quality monitoring, and serves as a subject matter resource to team members to ensure operational excellence and compliance with CMS and organizational standards.

Requirements

• High School Diploma or GED
• Minimum of 3+ years of experience as a Medical Claims Examiner.
• Strong experience with contract interpretation and benefit application.
• Working knowledge of CMS guidelines, Medicare regulations, and healthcare claims processing standards.
• Strong analytical and problem-solving skills.
• Proficiency in Windows-based systems and claims processing applications.

Nice To Haves

• Experience processing Medicare Advantage and/or managed care claims preferred.

Responsibilities

• Review, analyze, and adjudicate professional and institutional claims, including high-dollar and complex cases.
• Process Member Reimbursement claims in accordance with plan benefits and regulatory guidelines.
• Ensure claims are processed accurately, timely, and in compliance with CMS regulations, state guidelines, and internal policies.
• Assist the Claims Manager and/or Assistant Director in monitoring daily, weekly, and monthly workflow to meet production and quality targets.
• Generate and analyze reports to track productivity, aging inventory, and pending items.
• Provide guidance and clarification to team members regarding claims processing rules, contract interpretation, and system functionality.
• Support the implementation and enforcement of departmental policies and procedures.
• Collaborate with leadership to ensure production, accuracy, and turnaround time metrics are consistently met.
• Communicate departmental goals, workflow strategies, and performance improvement initiatives to staff.
• Promote a positive work environment that supports staff engagement, accountability, and teamwork.
• Maximize system capabilities by ensuring proper utilization of claims processing tools and platforms.
• Identify process improvement opportunities and escalate system or configuration issues as needed.
• Perform additional duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 11-50 employees