Claims Examiner

Our client is seeking an experienced Medical Claims Examiner to support a healthcare claims review and audit project focused on commercial health plans. This fully remote contract opportunity will play a key role in evaluating claims accuracy, identifying compliance risks, and supporting audit-related initiatives. The ideal candidate will have strong claims analysis experience, knowledge of healthcare reimbursement practices, and familiarity with the No Surprises Act.

Key Responsibilities

• Review commercial medical claims to verify processing accuracy, payment integrity, and compliance with established policies and audit requirements.
• Analyze claims impacted by the No Surprises Act (NSA) , investigating supporting documentation and identifying discrepancies, exceptions, or areas requiring escalation.
• Conduct detailed claim reviews and maintain audit documentation to support findings, recommendations, and corrective actions.
• Collaborate with claims operations, compliance, and internal business partners to resolve claim-related issues and ensure adherence to regulatory guidelines.
• Evaluate denied, rejected, and adjusted claims to identify trends, root causes, and opportunities to strengthen processes and controls.
• Perform reviews across multiple plan structures and jurisdictions while ensuring consistent application of payer policies and coverage requirements.
• Utilize healthcare claims systems and reporting tools to document results, track audit activity, and support project deliverables.

Qualifications

• Previous experience working with healthcare or medical claims within a health plan, payer organization, TPA, or related environment.
• Experience conducting claims audits, investigations, quality reviews, or examiner-level claims analysis.
• Solid understanding of commercial insurance claims processing and medical billing practices.
• Knowledge of claim denials, rejected claims, payment adjustments, and common processing errors.
• Familiarity reviewing claims subject to varying state regulations and compliance requirements.
• Direct knowledge of the No Surprises Act (NSA) is required.
• Strong analytical and problem-solving skills with the ability to identify discrepancies, interpret claims data, and clearly document findings.