Medical Claims Examiner

Job Description

Job Description

We are looking for a detail-focused Medical Claims Examiner to join an insurance organization in Greenville, South Carolina. This position is suited for someone with hands-on experience adjudicating medical claims and applying plan provisions, coding standards, and pricing rules with accuracy. The person in this role will help ensure claims are processed efficiently, in compliance with benefit plans, contractual arrangements, and regulatory requirements.

Responsibilities:
• Review and adjudicate medical, dental, vision, and flexible spending account claims from intake through final payment determination.
• Examine suspended or flagged claims to identify billing discrepancies, duplicate submissions, unbundled charges, or other questionable claim activity.
• Resolve system-related claim exceptions by making manual corrections before claims are finalized for payment.
• Apply member benefits, provider contract terms, fee schedules, and applicable regulations to calculate accurate reimbursement outcomes.
• Interpret coding and billing details, including diagnosis and procedure information, to support proper claim handling.
• Escalate complex claim issues or unclear situations to leadership when additional review or guidance is needed.
• Manage assigned exception reports and follow through on outstanding claim items in a timely manner.
• Meet established productivity, turnaround, and quality expectations while maintaining dependable attendance at the Greenville, South Carolina worksite.