Claims Examiner I

Claims Examiner I

We are seeking a detail-oriented Claims Examiner I to join our Claims team. This role is responsible for reviewing, analyzing, and adjudicating medical claims accurately and within established regulatory timelines. The ideal candidate will ensure claims are processed in accordance with contractual agreements, internal policies, and applicable state and federal regulations while maintaining high standards of quality, accuracy, and productivity.

Responsibilities

• Review and adjudicate medical claims accurately and efficiently.
• Determine the appropriate payer based on coding, contractual agreements, service areas, and Division of Financial Responsibility (DoFR) guidelines.
• Analyze claims and make payment determinations in accordance with company policies and regulatory requirements.
• Process claims adjustments and corrections as needed.
• Review and process member reimbursement requests within required turnaround times.
• Ensure claim payments are issued at the appropriate contracted rates.
• Maintain departmental quality and audit standards.
• Forward misdirected claims to the appropriate payer within established timelines.
• Meet regulatory requirements and internal service-level standards for claims processing and resolution.
• Ensure clean, unclean, and contracted claims are processed within required timeframes.
• Accurately document claim determinations, denials, and payment decisions.
• Consistently meet productivity, accuracy, and timeliness goals.
• Assist with special projects and perform additional duties as assigned.

Qualifications

• High School Diploma or equivalent required.
• Minimum of 1 year of medical claims adjudication experience within the healthcare industry; HMO experience preferred.
• Working knowledge of medical claim processing practices and healthcare reimbursement methodologies.
• Understanding of medical coding standards, including:
• ICD (International Classification of Diseases)
• CPT (Current Procedural Terminology)
• Revenue Codes
• Strong analytical and problem-solving skills.
• Excellent attention to detail and accuracy.
• Ability to interpret policies, procedures, contracts, and regulatory guidelines.
• Effective verbal and written communication skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficiency with Microsoft Office applications, including Outlook, Word, and Excel.
• Familiarity with state and federal healthcare regulations, including ERISA guidelines.

Benefit offerings include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits, and 401K plan. Our program provides employees the flexibility to choose the type of coverage that meets their individual needs. Available paid leave may include Paid Sick Leave, where required by law; any other paid leave required by Federal, State, or local law; and Holiday pay upon meeting eligibility criteria.

Equal Opportunity Employer/Veterans/Disabled Military connected talent encouraged to apply.