Job Title: Medical Claims Examiner

Overview:
We are seeking a detail-oriented Medical Claims Examiner with 3-5 years of experience to review, evaluate, and process healthcare claims in accordance with plan guidelines, policies, and regulatory requirements. This role plays a key part in ensuring accurate and timely claims adjudication while maintaining compliance and high service standards.

Key Responsibilities:

• Review and adjudicate medical claims for accuracy, completeness, and eligibility based on plan benefits and policies
• Apply appropriate coding knowledge (CPT, ICD-10, HCPCS) to ensure correct claim processing
• Analyze claim documentation, including medical records, provider submissions, and billing statements
• Identify discrepancies, errors, or potential fraud/abuse and escalate as needed
• Process adjustments, denials, and reprocessing requests in accordance with guidelines
• Maintain productivity and quality standards while meeting turnaround time requirements
• Collaborate with internal teams (e.g., customer service, provider relations) to resolve claim issues
• Ensure compliance with HIPAA, regulatory requirements, and organizational policies

Qualifications:

• 3-5 years of experience in medical claims examination, adjudication, or processing
• Strong knowledge of healthcare claims workflows and medical terminology
• Familiarity with CPT, ICD-10, and HCPCS coding systems
• Experience working with health plans, TPAs, or managed care organizations preferred
• High attention to detail and analytical skills
• Strong communication and problem-solving abilities
• Proficiency with claims systems and Microsoft Office applications

Preferred Qualifications:

• Experience with high-volume claims processing environments
• Exposure to Medicare, Medicaid, or commercial health plan claims
• Understanding of MSO or provider-side claims workflows is a plus

Work Environment:
Fast-paced, detail-driven environment requiring strong organizational skills and the ability to manage multiple priorities effectively.