Medical Claims Examiner II

Gravie

8d•$22 - $30

About The Position

As Gravie looks to continue its member-centric approach to healthcare, the Medical Claims Examiner II will support, review and adjudicate claims in our best in class claim system. They are a subject matter expert capable of thoroughly evaluating, researching, and analyzing claim submissions with a solid knowledge of national claims guidelines. In addition to owning a high-volume, high-complexity caseload, this role may serve as a go-to resource for other Examiners, contribute to training and special projects, and support leadership with inventory management, process development, and auditing.

Requirements

High School Diploma
4 + years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment
Strong knowledge of CPT/HCPC and ICD-10 code rules
Ability to set priorities, manage time and work independently
Functional comfort with Zoom, Microsoft Teams, or Google Meets
General knowledge of CMS claims submission regulations
Strong collaboration and communication skills within a team setting

Nice To Haves

Medical Coding experience/certification
Medical Billing experience
Understanding of provider data
Degree in Healthcare Administration or similar field
Previous experience using Javelina processing system
Experience with training and ability to create processes/procedure documentation
Previous start-up company experience

Responsibilities

Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures
Process complex claim scenarios in accordance with Summary Plan Descriptions (SPDs). Areas of expertise include, but are not limited to: Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing.
Review claims queues and provide expertise to address nuances with appropriate parties.
Serve as a go-to resource for other Examiners, answering questions and helping resolve claims issues as they arise
Continually meet department metrics and quality standards set forth by leadership
Communicate complex claims issues clearly through documentation and direct communication
Provide ongoing feedback to leadership on workflow gaps, process improvements, system enhancements, and training needs
Support leadership with special projects as assigned, including inventory management, process development, and auditing