Xcelys Medical Claims Examiner (Remote)

Claims Examiner-Xcelys

To serve as a Medical Claims Processor within the Xcelys environment. Provide subject-matter expertise on claims workflows and be a key contributor to system enhancements, audits, and process optimizations.

Role Responsibilities:

1. Adjudication & Review
• Process comprehensive medical claims using Xcelys and associated subsystems
• Resolve complex pends, coding issues, and contract exceptions
• Author overpayment/underpayment determinations and coordinate appeals
2. Quality & Compliance
• Engage in quality reviews, audits, root cause analyses
• Monitor accuracy, variance, and rework metrics
• Ensure alignment with regulatory and internal compliance guidelines
3. Support
• Act as escalation point and subject matter expert
4. Process & System Improvement
• Participate in system testing, UAT, and workflow enhancements
• Recommend improvements, document system and process changes
5. Reporting & Analytics
• Prepare production, pending, and quality reports
• Identify trends and recommend corrective actions
6. Cross-Functional Collaboration
• Liaise with provider relations, legal, IT, compliance teams
• Support internal initiatives related to claims systems / operational improvements

Required Skills/Experience:

• 2+ years claims adjudication experience
• Minimum of 1 year experience in Xcelys
• 2+ years in coding (CPT, ICD-10, HCPCS)
• 2+ years provider contracts, pricing, regulatory guidelines experience

Preferences:

• Excellent analytical and communication skills
• Experience training staff or acting as a mentor
• Familiarity with system testing and documentation
• Ability to manage high-volume workload and meet performance metrics

Education: Verifiable high school diploma or GED

Pay Rate: $20.00 Per hour