Claims Examiner (Provider Dispute) - Potential WFH after Training

ImageNetLLC

6d•Hybrid

About The Position

The Claims Examiner (Provider Dispute) reviews, researches, and resolves provider disputes involving denied, underpaid, or incorrectly processed claims, in compliance with regulatory guidelines and internal policies. The role requires practical knowledge of Medi-Cal and commercial insurance claims and supports provider satisfaction while meeting dispute-resolution timelines. The position also involves processing and reviewing healthcare claims across multiple specialties, verifying eligibility, coverage, codes, authorization details, and supporting documentation, and determining whether claims should be approved, denied, or adjusted. The position requires in-office training in Makati–Valero. Remote work may be available after successful completion of training, but the company may require onsite work based on business needs, performance evaluations, or operational requirements.

Requirements

High school diploma or equivalent.
At least 3–5 years of hands-on provider dispute resolution experience in healthcare, a third-party administrator, or a health plan, including claims processing and adjudication.
Proficiency in validating CPT, ICD-10, and HCPCS codes.
Experience handling Medicare claims and secondary coverage.
Experience with claims denials, adjustments, and appeals.
Strong knowledge of authorization and eligibility verification.
Familiarity with HIPAA, data privacy regulations, and basic cybersecurity standards.
Strong background in data analysis and visualization to identify trends, improve workflows, and support decision-making.
Experience with claims adjudication systems such as IDX and Facets.
Proficiency in Microsoft Office Suite, including Excel, Outlook, and Word; advanced Excel skills.
Ability to complete in-office training and transition to an office-based setup when required.

Nice To Haves

Associate or bachelor’s degree.

Responsibilities

Investigate and resolve provider disputes involving denied, underpaid, or incorrectly processed claims.
Use EZCap to review claims history, adjudication data, and notes.
Interpret health plan policies, provider contracts, and regulatory requirements, particularly for Medi-Cal and commercial plans.
Review healthcare claims across multiple specialties, including Anesthesia, ARI, DME, Facility, MSK, Surgery, PAP Supplies, COB, and Lab.
Verify eligibility, coverage, CPT codes, and supporting documentation for Primary and Secondary Medicare claims.
Identify discrepancies and determine whether to approve, deny, or adjust claims in accordance with policy guidelines and medical necessity.
Maintain claims adjudication accuracy and meet turnaround-time and quality-assurance standards.
Collaborate with internal quality auditors.