Claims Examiner

About This Role

This fully remote contract opportunity involves supporting a healthcare claims review and audit project focused on commercial health plans. The role plays a key part in evaluating claims accuracy, identifying compliance risks, and supporting audit-related initiatives, and suits a candidate with strong claims analysis experience, knowledge of healthcare reimbursement practices, and familiarity with the No Surprises Act.

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

Requirements

• 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