Medical Claims Examiner II

Role Overview

• Support team discussions, aid in team claims issue resolution efficiently, and lead by example.
• Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures
• Foster a collaborative team culture through open, honest communication.
• Assist with training new team members and support ongoing development through continuous education and skills training.
• Support in helping develop team members to perform at their highest level by offering coaching and sharing expertise/best practices.
• Review claims queues and provide expertise to address nuances with appropriate parties.
• Continually meet department metrics and quality set forth by leadership Provide ongoing feedback to improve departmental workflows and procedures.
• Communicate complex claims issues clearly through documentation and direct communications.
• Process complex claim scenarios in accordance with Summary Plan Descriptions (SPDs). Areas of expertise include, but are not limited to: Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing.
• Provide feedback to leadership on system enhancements or training gaps.

Requirements

• High School Diploma
• 4 + years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment
• Strong knowledge of CPT/HCPC and ICD-10 code rules
• Ability to set priorities, manage time and work independently
• Basic proficiency using Windows based other computer applications
• Functional comfort with Zoom, Microsoft Teams, or Google Meets
• General knowledge of CMS claims submission regulations
• Demonstrated success getting results through collaboration
• Excellent facilitation and transferable knowledge skills communicating effectively on complex concepts
• Extra credit:
• Medical Coding experience/certification
• Medical Billing experience
• Understanding of provider data
• Previous start-up company experience
• Degree in Healthcare Administration or similar field
• Training and ability to create processes/procedure documentation is a plus
• Previous experience using Javelina processing system

Benefits

• Alternative medicine coverage
• Flexible PTO
• Up to 16 weeks paid parental leave
• Paid holidays
• 401k program
• Cell phone reimbursement
• Transportation perks
• Education reimbursement
• 1 week of paid paw-ternity leave