Claims Examiner I

Primary Responsibilities

• Review and adjudicate claims submitted for reimbursement that fall outside auto adjudication standards on a daily basis, ensuring compliance with quality, productivity, and timeliness requirements. 

• Applying medical policies, contractual provisions, and operational procedures to ensure precise adjudication and adjustments. 

• Generate correspondence, such as letters and questionnaires, to gather additional information from customers and providers; may also initiate phone inquiries. 

• Collaborate with Customer Service to address and resolve customer inquiries and concerns effectively. 

• Research and resolve client inquiries and escalations in a timely manner, collaborating with internal teams as needed to ensure effective resolution. 

• Execute client-requested claim adjustments and provide clear, concise written responses to client inquiries within established deadlines. 

• Perform in-depth research on account receivables and spreadsheets that require claim adjustments, delivering thorough and clarifying responses to providers and clients. 

• Must be adaptable and willing to provide backup support across various departments and roles as needed 

Essential Qualifications

• Strong knowledge of healthcare contracts, medical terminology, and claims processing procedures. 

• Prior experience processing claims is required. 

• Minimum 1 year of experience in medical billing, claims adjudication, or a related role. 

• Excellent written and verbal communication skills, with the ability to manage inquiries professionally and efficiently. 

• Strong analytical skills with the ability to research and resolve complex claim issues. 

• Proficiency in Microsoft Office Suite, particularly Microsoft Word and Excel. 

• Ability to meet production and quality standards while managing multiple priorities. 

• Strong problem-solving skills and the ability to maintain professionalism under pressure.