Review and adjudicate medical claims, ensuring accurate coding, data entry, and application of appropriate reimbursement methodologies
Verify patient eligibility, provider credentialing, and coverage details to facilitate accurate claims processing.
Communicate with internal resources, and internal stakeholders to resolve claim discrepancies, request additional information, or clarify issues.
Review, evaluate and process all types of claims such as Encounter data, Professional and Institutional Claims for all lines of business e.g., Commercial, Point of Service (POS) Senior/Medicare, Preferred Provider Organization (PPO), Medi-Cal, etc.
Ensure claims payment & denial accuracy and compliance to turnaround time
Participate in ongoing training and professional development activities.
Maintain accurate and detailed records of claims processing activities.
Identify and escalate complex or unusual claims for further review or investigation.
Handle more complex claims with multiple services, providers

2+ years of experience working closely with healthcare claims or in a claims processing/adjudication environment.
Understanding of health claims processing/adjudication
Medical terminology strongly preferred
Understanding of ICD-9 & ICD-10
Ability to perform basic to intermediate mathematical computation routines
Basic MS office computer skills
Ability to work independently or within a team
Time management skills
Written and verbal communication skills
Attention to detail
Must be able to demonstrate sound decision-making skills.

Medical Claims Examiner

Key skills