Claims Examiner

Join Our Team as an Insurance Claims Examiner - Make an Impact in Healthcare Payment Accuracy! Are you passionate about ensuring fair and accurate healthcare claims processing? We're seeking a dedicated Insurance Claims Examiner to join our dynamic team in Doral, FL, and play a vital role in managing healthcare claims within Medicare and Dual Eligible Special Needs Plans (DSNP). If you thrive in a fast-paced environment, possess a keen eye for detail, and are committed to compliance, this is your chance to contribute to meaningful healthcare solutions while advancing your career. As an Insurance Claims Examiner, you will be responsible for the precise adjudication of medical claims, applying benefit plans and regulatory guidelines to uphold payment accuracy and member satisfaction. Your expertise will help support the integrity of the claims process, ensuring timely resolutions and compliance with industry standards. Required Skills and Qualifications: High school diploma or equivalent; associate or bachelor's degree preferred 2-4+ years of claims processing experience in a managed care or health insurance setting Strong knowledge of Medicare and DSNP claims guidelines, including benefits and COB Experience with claims reprocessing, disputes, and appeals, including overturned cases Proficiency with CPT, HCPCS, ICD-10 coding Ability to interpret provider contracts, fee schedules, and reimbursement methods Excellent analytical, problem-solving, and communication skills Proficiency in claims processing systems and Microsoft Office Nice to Have Skills: Knowledge of CMS regulations and audit standards Prior experience working with dual-eligible populations Medicare Part C claims processing experience Preferred Education and Experience: Associate or bachelor's degree Extensive experience handling claims in managed care environments, especially with Medicare and DSNP programs Other Requirements: Ability to handle multiple priorities efficiently A track record of maintaining high quality and productivity metrics Willingness to participate in audits, quality reviews, and continuous improvement initiatives #J-18808-Ljbffr Ascendo-Resources