Claims Examiner I-III
About The Position
A healthcare IPA is seeking experienced Claims Examiners for multiple long-term openings at Level I, II, and III. Candidates must have prior healthcare claims adjudication experience, preferably within a managed care, IPA, medical group, or health plan environment. The Claims Examiner is responsible for reviewing, researching, adjusting, and adjudicating healthcare claims accurately and timely. This includes professional and facility claims, coding review, benefit interpretation, pricing, provider billing issues, and compliance with claims processing guidelines. Remote or hybrid work may be offered after training once performance metrics are exceeded and consistently sustained.
Requirements
- Minimum of 2 years of healthcare claims adjudication experience required.
- Experience processing professional and/or facility claims.
- Knowledge of CMS-1500 and UB-04 claim forms.
- Familiarity with CPT, HCPCS, ICD coding, revenue codes, APC, ASC, DRG pricing, CMS, DMHC regulations, and claims billing practices.
- Strong attention to detail and accuracy.
- Ability to research, analyze, and resolve claim issues.
- Strong organizational skills and ability to meet productivity and quality standards.
- Ability to work independently and as part of a team.
- Good communication skills and ability to interact professionally with providers, health plans, supervisors, and internal staff.
- Dependable, punctual, and able to maintain consistent attendance.
- Prior healthcare claims experience with ability to process routine claims accurately and follow established guidelines (Claims Examiner I).
- Strong claims adjudication experience with ability to handle more complex claims, research issues, and work with limited supervision (Claims Examiner II).
- Advanced claims adjudication experience, including complex, high-dollar, facility, contract, pricing, or regulatory claims review (Claims Examiner III).
Nice To Haves
- Experience in managed care, IPA, medical group, MSO, TPA, or health plan claims preferred.
Responsibilities
- Review, analyze, research, adjust, and adjudicate healthcare claims.
- Process professional claims, including CMS-1500 forms.
- Process facility claims, including UB-04 forms.
- Apply appropriate CPT, HCPCS, ICD diagnosis/procedure codes, revenue codes, and benefit guidelines.
- Review claims according to provider contracts, health plan guidelines, division of financial responsibility, regulatory requirements, and company policies.
- Review member benefits, copayments, deductibles, authorizations, and claim payment rules.
- Identify provider billing issues that may impact claims processing.
- Review charges for accuracy and appropriateness during claims processing.
- Research and resolve provider or health plan claims inquiries in a timely manner.
- Monitor pended, aged, open, or assigned claim reports to maintain processing timelines.
- Maintain required quality and productivity standards.
- Communicate claim issues, system concerns, or training needs to the Claims Supervisor.
- Follow all company policies, compliance guidelines, HIPAA requirements, and applicable federal, state, and regulatory standards.
- Perform other duties and projects as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
