Claims Examiner

Claims Examiner – Vision Insurance

The Claims Examiner – Vision Insurance is a key contributor within the Claims Department, responsible for accurately adjudicating vision and eye care claims in compliance with Medicaid, Medicare, and commercial payer guidelines. This role supports operational excellence by ensuring timely payments, regulatory compliance, and high-quality service to providers and internal stakeholders. The Claims Examiner plays an active role in meeting departmental performance metrics and supporting audits, reporting, and workflow oversight.

This is a fully on-site role, and employees are expected to report to the Clifton, New Jersey office five days per week.

Key Responsibilities

• Review, evaluate, and adjudicate vision and eye care insurance claims in accordance with payer guidelines, including Medicaid, Medicare, and Coordination of Benefits (COB) rules
• Process complex or high-dollar claims requiring supervisory overrides
• Distribute daily claim workloads and support operational workflow efficiency
• Prepare and maintain documentation for internal and external audits
• Ensure compliance with prompt pay regulations and timely filing requirements
• Research and resolve rejected, denied, or pending claims, including billing corrections and resubmissions
• Analyze remittance advice (EOBs/ERAs) and communicate findings as needed
• Support monthly claims reporting and departmental performance tracking
• Collaborate with leadership to meet monthly productivity and accuracy goals
• Respond promptly and professionally to internal and external communications
• Perform additional duties as assigned to support claims operations and leadership initiatives

Required Qualifications:

• 5+ years of experience adjudicating and processing healthcare claims, preferably in vision insurance or eye care
• Strong knowledge of Medicaid and Medicare claim processing
• Proficiency with CPT, ICD-10, HCPCS codes, and modifiers, including billing and coding edits
• Solid understanding of Third-Party Liability (TPL) and Coordination of Benefits (COB) rules
• Experience with electronic claims submission, clearinghouses, and billing resubmission processes
• In-depth knowledge of HCFA-1500 (CMS-1500) and electronic billing standards
• Familiarity with appeals and reconsideration processes for government payers
• Experience researching and resolving claim denials and timely filing issues
• Working knowledge of AS400 or similar claims processing systems
• Intermediate to advanced Microsoft Office skills, with emphasis on Excel
• Strong attention to detail, analytical skills, and ability to manage deadlines in a high-volume environment

Preferred Qualifications:

• Previous leadership experience would be preferred
• Certified Professional Coder (CPC/CBC) and/or Certified Professional Biller (CPB)
• Prior experience in vision plans, optometry, ophthalmology, or eye care billing
• Experience supporting or participating in claims audits or compliance reviews

Why Join Us?

• Be part of a collaborative claim's leadership-focused environment
• Opportunity to specialize in eye care and vision insurance claims
• Role offers stability, growth, and exposure to complex adjudication and compliance work

National Vision Administrators

For over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health & Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey.

We are an equal opportunity employer

Monday - Friday 8:30am - 5:00pm