Senior Medical Claims Examiner

Senior Claims Examiner

The Senior Claims Examiner is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and desktops, as well as, ensuring compliance with federal regulations. This role works in conjunction with Business Configuration, Network Management, Provider Data, Complaints, Appeals and Grievances as well as other operational departments to ensure validation and quality assurance of claims processing.

Roles And Responsibilities

• Meets expectations of the applicable One client's Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines

Minimum Qualifications

• Associate's degree or equivalent job-related experience required.
• Minimum of 3 years' experience processing medical claims in the healthcare industry.
• Prior experience working with managed care, Medicare, Medicare Advantage, Health Exchange, and TRICARE are highly desirable.
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.