Claims Examiner II

About the Role

The day-to-day responsibilities of this role will involve reviewing claims, determining eligibility and benefit levels, and collaborating with other departments to resolve issues. You will also be responsible for identifying and escalating complex issues to your lead or supervisor, as well as generating letters and other documents as needed.

What You Will Do

• Adjudicate medical, dental, and mental health claims in accordance with plan provisions, state and federal regulations, and company policies and procedures
• Re-adjudicate, adjust, or correct claims, including complex and difficult claims as needed
• Meet or exceed quality and production standards established by the department and company
• Provide excellent customer service to internal and external customers
• Collaborate and share information with Claims teams and other departments to achieve excellent customer service and support organizational goals
• Determine eligibility, benefit levels, and coordination of benefits with other carriers
• Recognize and escalate complex issues to the Lead or Supervisor as needed
• Investigate third-party issues as directed
• Review, process, and post refunds and claim adjustments or re-adjudications as needed
• Report any overpayments, underpayments, or other possible irregularities to the Lead or Supervisor as appropriate
• Generate letters and other documents as needed

What We Are Looking For

• 2 years of experience as a Medical Claims Examiner or other role that requires knowledge of medical coding and terminology
• Knowledge of CPT, HCPCS, Revenue, CDT, and ICD-10 coding
• Understanding of state and federal laws and other regulatory agency requirements that relate to the medical, dental, mental health, and health insurance industry
• Strong spoken and written communication skills
• Basic computer skills, including Microsoft Outlook, Word, and Excel
• Ability to perform fast and accurate data entry
• Good customer service skills
• Ability to participate fully and constructively in meetings
• Strong analytical and sound problem-solving skills
• Detail orientation and strong organizational skills

Nice to Have

• Experience using QNXT, Facets, or Epic systems
• Knowledge of medical, dental, mental health, and health insurance terminology
• 2 years of experience as a Medical Claims Examiner
• Certification in medical coding or a related field

Benefits and Perks

• Competitive salary and bonus structure
• Comprehensive health insurance plan
• Retirement savings plan
• Paid time off and holidays
• Remote work options
• Opportunities for professional development and growth
• Collaborative and dynamic work environment
• Recognition and reward programs

• Be prepared to highlight your knowledge of medical coding and terminology, as well as your analytical and problem-solving skills.
• Make sure to showcase your experience with claims adjudication and regulatory compliance.
• Familiarize yourself with the company's policies and procedures, as well as industry standards and regulations.
• Develop a strong understanding of the company's products and services, and be able to articulate how you can contribute to their success.
• Be prepared to provide specific examples of your experience and accomplishments, and to explain how they relate to the role.
• Consider obtaining certification in medical coding or a related field to increase your competitiveness for the role.
• Research the company's culture and values, and be prepared to discuss how you can contribute to and thrive in that environment.