Claims Examiner I

Job Summary:

The Claims Examiner is responsible for the accurate and timely adjudication of healthcare claims within a managed care environment, with a focus on Dual Eligible Special Needs Plans (DSNP) and Medicare lines of business. This role involves applying benefit plans, policies, and regulatory guidelines to ensure proper claim processing, including new claims, reprocessed claims, overturned disputes, and appeals. The Claims Examiner plays a critical role in maintaining compliance, ensuring payment accuracy, and supporting member and provider satisfaction.

Key Responsibilities:

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• Review, analyze, and process medical claims in accordance with Medicare and DSNP benefit structures, policies, and procedures.
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• Accurately adjudicate new day claims, ensuring proper application of benefits, coding edits, and pricing methodologies.
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• Reprocess claims resulting from overturned disputes and appeals, ensuring adjustments reflect updated determinations and regulatory requirements.
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• Evaluate and process claim disputes and reconsiderations, including those that result in overturn decisions requiring correction and re-adjudication.
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• Handle appeals-related claim adjustments, ensuring timely and accurate implementation of appeal outcomes.
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• Interpret provider contracts, fee schedules, and reimbursement methodologies to ensure correct payment.
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• Ensure compliance with CMS (Centers for Medicare & Medicaid Services), state regulations, and internal policies.
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• Identify and escalate complex claim issues, system errors, or potential compliance risks.
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• Maintain productivity and quality standards, meeting turnaround time requirements for all claim types.
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• Document claim processing activities clearly and accurately in system notes.
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• Collaborate with internal departments such as Provider Relations, Appeals & Grievances, and Configuration teams to resolve claim issues.
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• Participate in audits, quality reviews, and continuous improvement initiatives.
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Required Qualifications:

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• High school diploma or equivalent; associate or bachelor’s degree preferred.
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• Minimum of 2–4 years of claims processing experience in a managed care or health insurance environment.
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• Strong knowledge of Medicare and DSNP claims processing guidelines, including benefit application and coordination of benefits (COB).
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• Experience handling claim reprocessing, disputes, and appeals (including overturned cases).
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• Familiarity with CPT, HCPCS, and ICD-10 coding.
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• Understanding of provider contracts and reimbursement methodologies.
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• Strong analytical and problem-solving skills with high attention to detail.
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• Ability to manage multiple priorities in a fast-paced environment.
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• Proficiency in claims processing systems and Microsoft Office applications.
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Preferred Qualifications:

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• Knowledge of CMS regulations and audit requirements.
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• Prior experience working with dual-eligible populations.
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• Medicare, Part C claims processing experience.
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Core Competencies:

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• Accuracy and attention to detail
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• Regulatory compliance awareness
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• Critical thinking and decision-making
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• Time management and productivity
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• Communication and collaboration
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