Job Title: Medical Claims Examiner

Department: Claims Operations
Reports To: Claims Supervisor or Manager
Industry: Healthcare / Health Insurance

Position Summary

The Medical Claims Examiner is responsible for reviewing, analyzing, and adjudicating medical insurance claims in accordance with policy provisions, regulatory guidelines, and organizational procedures. This role ensures accurate and timely processing of claims while maintaining compliance with federal and state regulations and providing high-quality service to providers and members.

Key Responsibilities

• Review and evaluate medical claims for accuracy, completeness, and eligibility
• Adjudicate claims in accordance with benefit plans, contract terms, coding guidelines, and company policies
• Verify coverage, benefits, modifiers, and authorization requirements
• Apply appropriate medical, contractual, and reimbursement rules when determining claim payment
• Identify and resolve claim discrepancies, denials, adjustments, and appeals
• Request and review additional documentation when required (e.g., medical records, authorizations)
• Ensure compliance with regulatory requirements including HIPAA and CMS guidelines
• Communicate claim determinations clearly and professionally to providers, members, and internal teams
• Maintain accurate documentation and records within claims processing systems
• Meet productivity, quality, and turnaround-time standards

Required Qualifications

• High school diploma or equivalent; associate's degree preferred
• 1-3 years of experience in medical claims processing, healthcare administration, or insurance operations
• Knowledge of medical terminology, CPT, ICD-10, and HCPCS coding
• Familiarity with health insurance benefit plans and reimbursement methodologies
• Strong analytical and attention-to-detail skills
• Ability to work efficiently in a high-volume, deadline-driven environment
• Proficiency with claims adjudication systems and Microsoft Office applications

Preferred Qualifications

• Experience with commercial, Medicare, or Medicaid claims
• Familiarity with provider contracts and payer policies
• Prior experience handling claim appeals or complex medical claims
• Certification such as CPC, CPB, or other healthcare-related credentials

Key Competencies

• Accuracy and attention to detail
• Analytical and problem-solving skills
• Time management and organizational skills
• Ability to interpret policies and regulatory guidelines
• Professional written and verbal communication
• Confidentiality and ethical judgment

Work Environment

• Office-based, hybrid, or remote setting (depending on organization)
• Prolonged periods of computer and system use
• Fast-paced environment with performance metrics and quality standards