About This Role
This role involves the highly complex review and adjudication of medical claims, including advanced claim history analysis and the resolution of complex appeals and reconsiderations. The examiner will serve as a senior escalation point and subject-matter resource for intricate claim issues, supporting the claims team with guidance and training.
Responsibilities
- Manage highly complex medical claim reviews
- Perform advance claim adjudication
- Conduct advance claim history analysis
- Handle complex appeals and reconsiderations
- Resolve escalated claims
- Address complex provider and payer issues
- Investigate complex duplicate claims
- Conduct Payer Audit-related claim reviews
- Process complex void and replace transactions
- Resolve advance reprocessing issues
- Research system and adjudication issues
- Review recurring claim-processing problems
- Identify opportunities for process improvement
- Assist with system and workflow validation
- Provide subject-matter expertise to Levels 1 and 2
- Provide guidance and mentoring to Claims team members
- Assist with training and knowledge transfer
- Support development and refinement of claims procedures
- Serve as a senior escalation and subject-matter resource for complex claim issues
Requirements
- High School diploma or equivalent
- 3 years’ work experience in a claims operations environment in healthcare insurance processing Medicare
- Hands-on working experience processing medical claims in the insurance industry
- Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat fees)
- Self-starter, ability to work independently and in a team environment
- Strategic, analytical, process-oriented, and critical thinking skills
- Excellent written and verbal communication skills
- Ability to manage multiple priorities
- Excellent problem-solving skills, good follow-up abilities, and willingness to be flexible and adaptable to changing priorities
- Works well under pressure
- Proficient with Excel, PowerPoint, Word & Outlook
- Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10 Codes, and Revenue Codes
- Knowledge of Correct Coding (CCI) Edits
- Experience in gathering all necessary documentation in preparation of Delegation Audits
- Detailed knowledge of electronic billing processes universal billing forms
Nice to have:
- Knowledge of CMS/ACHA Regulations
- Previous experience using Health Suite
- Certified Professional Coder (CPC)
About the Company
The Senior Medical Claims Examiner is the highest individual contributor level within the Claims processing structure and serves as a subject-matter resource for complex claims, escalations, appeals/reconsideration and process-related issues requiring additional research, documentation review, or independent analysis.