We are seeking an experienced Medical Claims Examiner to review, analyze, and adjudicate medical claims for accuracy, compliance, and medical necessity. The ideal candidate has strong working knowledge of ICD-9 and ICD-10 diagnosis coding and healthcare billing standards.

Key Responsibilities:

• Review and process medical claims for completeness, accuracy, and compliance
• Apply ICD-9 and ICD-10 codes to evaluate claim validity
• Identify coding discrepancies, overpayments, and potential fraud or abuse
• Ensure claims adhere to payer policies, CMS guidelines, and regulatory requirements
• Document determinations and communicate findings as needed

Qualifications:

• Proven experience as a Medical Claims Examiner or similar role
• Strong knowledge of ICD-9 and ICD-10 coding
• Familiarity with CPT, HCPCS, and medical billing guidelines
• Attention to detail and strong analytical skills
• Proficiency with claims processing systems and MS Office

Preferred:

• CPC, CCS, or related certification
• Experience with Medicare, Medicaid, or commercial insurance claims