Claims Examiner

MagnaCare • Melville, NY

1d

About The Position

The Claims Examiner is responsible for applying medical policy, contractual provisions, and operational procedures to ensure accurate Medical claims. This role involves resolving claim holds, reviewing history records, and determining benefit eligibility for services rendered. The Claims Examiner will also research and document all pertinent information on claims requiring adjudication, and respond to inquiries related to specific claim issues via email, chat, or verbal communication. Additionally, the role includes performing non-standard claim data entry with detailed notation and documentation, completing assigned projects and tasks within established deadlines, and assisting other departments by providing support in resolving claims and responding to questions. The Claims Examiner is expected to meet or exceed production and quality standards, escalate issues to management when appropriate, and perform other related duties to support departmental goals.

Requirements

• High School Diploma or GED required.
• 1 to 3 years of medical or hospital claims processing experience.
• Strong understanding of medical terminology, CPT/HCPCS and ICD coding, and benefits administration.
• Ability to interpret medical policies, provider contracts, and plan documents.
• Excellent analytical and problem-solving skills, with the ability to identify discrepancies and resolve complex claim issues.
• Proficiency with claims processing systems, data entry platforms, and standard office software (e.g., Microsoft Office).
• Strong written and verbal communication skills for interacting with internal teams and responding to inquiries.
• Ability to manage multiple tasks and meet performance standards for speed and accuracy

Responsibilities

• Apply medical policy, contractual provisions, and operational procedures to ensure accurate Medical claims.
• Resolve claim holds, review history records, and determine benefit eligibility for services rendered.
• Research and document all pertinent information on claims requiring adjudication.
• Respond to inquiries related to specific claim issues via email, chat, or verbal communication.
• Perform non-standard claim data entry, including detailed claim notation and documentation.
• Complete assigned projects and tasks within established deadlines.
• Assist Customer Service, Casualty, Medical Management, and Management teams by providing support in resolving claims and responding to questions and concerns.
• Meet or exceed production and quality standards established for the role.
• Escalate issues to the Manager or Supervisor when appropriate.
• Perform other related duties as assigned to support departmental goals.

What This Job Offers

• Career Level: Mid Level
• Education Level: High school or GED