Medical Claims Examiner

Job description




Under the general direction of Business Operations Manager or designee, the Medical Claims Examiner is responsible for processing professional and facility medical services claims by reviewing and inputting data into the claims payment system using standard policies, procedures and guidelines. This position will also be responsible for invoice adjudication/payments with contract terms as well as policy and procedures.  Interpret plan contract language and apply appropriate benefit coverages based on the plan provisions with high quality while meeting production standards as defined by management. Ensures the integrity of outside medical payments and verifies the accuracy of data, DRG codes and auditing related information. This position will also ensure that the invoice adjudication/payment is compliant with contract terms, as well as policy and procedures.  


Ensure timely processing of claims in order to enhance service delivery & client satisfaction. Works independently determining whether an issue needs internal escalation or direct client interaction. Performs business process assessments and makes recommendations in clear, concise summary format.




  • Follows claims adjudication process, within the claims transactional system, to assure that all claims are adjudicated in accordance with CMS rules and regulations, as well as in accordance with contractual obligations/timelines
  • Pursues and follows up on open and pended claims promptly and independently
  • Researches and investigates high complexity claims to determine if claims are both payable to our providers and invoiceable to our contractor in accordance with various policy provisions
  • Responsible for generating requests for additional information required to process a claim (i.e., incomplete authorization information, processing new provider and vendors)
  • Responsible to determine if correct billing/coding requirements have been met
  • Verifies payment and invoicing amounts are accurate, by analyzing claim extracts and utilizing systems, tools and resources available
  • Performs routine and random sampling audits of adjudicated claims to identify inaccurate claims adjudication.
  • Researches, trouble shoot and resolve errors and problem areas in claims entry and processing.
  • Identifies prevalent trends for inaccurate claims processing and adjudication. This will include developing and presenting potential solutions to management.
  • Assists in the development of action plans to address quality deficiencies.
  • Builds productive working relationships internally and externally. Works closely with various functions such as finance, contracting and operations to ensure lines of communication are kept open with processing or auditing related issues.
  • Works with community-based providers to stimulate the billing process by reviewing records to maintain documentation of outstanding charges.
  • Identifies and communicates claims system and/or billing problems to Manager
  • Authorizes claim payments within established contractual timelines
  • Analyses workflow to meet claims KPIs and targets
  • Supports claims payment and invoicing batching process
  • Analyzes and processes claim forms (UB-04 and CMS-1500) and reviews Medicare services for appropriateness of charges
  • Follows claims adjudication process to assure that all claims are adjudicated in accordance with CMS rules and regulations
  • Liaisons with staff responsible for daily transactional and business operations
  • Supports all department initiatives in improving overall efficiency
  • Meets department quality and production standards
  • Able to work and adjust priorities in a fast-paced environment
  • Performs other related duties as required



  • Bachelor’s Degree or equivalent
  • 3-5 years of claims processing, and a minimum of 2 years of claims quality assurance experience
  • Requires research, problem resolution & knowledge in the areas of contracts and Medicare regulations & reimbursement rules.
  • Experience with investigation, determination and reporting of claims processes
  • Experience identifying root cause claims adjudication process failures, ability to quantify program impact and present findings
  • Experience analyzing medical claims
  • Familiar with community-based health care medical systems and claims processing/adjudication processes
  • Knowledge of Medical Coding terminology, CPT, HCPC, ICD-10 & DRG codes
  • Demonstrated understanding and compliance with HIPAA privacy requirements
  • Experience with investigation, determination and reporting of claims processes
  • Familiar with community-based health care system medical systems and claims processing/adjudication processes
  • Must be able to read and interpret documents such as processing and procedure manuals, medical terminology and claims rules and regulations to appropriately adjudicate claims
  • Ability to meet performance deadlines in a dynamic environment
  • Demonstrated ability to create complex spreadsheets and reports, using Microsoft Excel, Microsoft Access and/or other systems as necessary and available
  • Demonstrated ability to analyze data with judgment ad discretion
  • Demonstrated organizational, interpersonal and problem-solving skills; Excellent oral and written communications skills
  • Demonstrated ability to handle details, multi-task, and prioritize work
  • Demonstrated proficiency with principles and methodologies of process improvement. Ability to apply these in the execution of responsibilities in support of a process focused approach
  • Communicates in a clear, and concise manner.


  • Certified Coder




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Job No:
Posted: 9/9/2020
Application Due: 12/8/2020
Work Type: