Experienced Managed Care Claims Examiner

ImagenetLLC

155d•Remote

About The Position

We are seeking an Experienced Managed Care Claims Examiner to join our growing healthcare operations team. This role is responsible for accurately reviewing, investigating, adjudicating, and resolving medical claims and provider dispute requests in accordance with payer guidelines, contractual agreements, regulatory requirements, and internal policies. This is a fast-paced, production-driven role requiring strong analytical skills, attention to detail, and the ability to process a broad range of claim scenarios. Successful candidates must be comfortable navigating complex claims, applying multiple benefit and reimbursement rules, and managing a high-volume workload while maintaining quality and accuracy standards. The ideal candidate is self-motivated, accountable, adaptable, and committed to continuous learning and professional growth.

Requirements

Minimum 3 years of healthcare claims adjudication experience, preferably within a managed care, health plan, TPA, or payer environment.
Experience processing medical claims from initial review through final adjudication.
Strong understanding of healthcare claims processing and reimbursement principles.
Demonstrated ability to research, analyze, and resolve claim discrepancies and exceptions.
Strong attention to detail and sound decision-making skills.
Ability to manage workload effectively and meet productivity expectations.
Effective written and verbal communication skills.
Ability to work independently and collaboratively within a team environment.
Basic to intermediate Microsoft Office skills.
Ability to perform basic mathematical calculations and verify claim accuracy.

Nice To Haves

Experience processing Provider Dispute Resolution (PDR), appeals, reconsiderations, and claim adjustments.
Managed care or health plan claims processing experience.
Experience processing multiple claim types and lines of business.
Knowledge of medical terminology.
Understanding of ICD-10, CPT, and HCPCS coding.
Experience handling complex claims requiring research, interpretation, and independent judgment.

Responsibilities

Review and adjudicate medical claims while ensuring accurate coding, data entry, and application of appropriate reimbursement methodologies.
Process a broad range of claim types, including professional, institutional, adjusted, corrected, and other complex claim scenarios.
Review and investigate provider dispute requests (PDRs), appeals, reconsiderations, and claim adjustments.
Verify member eligibility, provider participation, benefit coverage, and supporting documentation to facilitate accurate claim processing.
Research claim discrepancies and determine appropriate claim outcomes based on contractual agreements, benefits, policies, and regulatory requirements.
Request additional information and collaborate with internal stakeholders to resolve claim-related issues.
Process claims from initial review through final adjudication while maintaining thorough documentation of decisions and actions taken.
Handle complex claims involving multiple services, providers, benefits, or reimbursement methodologies.
Identify and escalate unusual or high-risk claims requiring additional review.
Maintain detailed and accurate records of claims processing activities.
Consistently achieve established productivity, quality, and timeliness standards.
Participate in training, calibration sessions, and ongoing professional development initiatives.