Claim Examiner I

Position Summary

The Claims Examiner I is responsible for the accurate and timely adjudication of healthcare claims within a managed care environment, with a focus on Dual Eligible Special Needs Plans (DSNP) and Medicare lines of business. This role involves applying benefit plans, policies, and regulatory guidelines to ensure proper claim processing, including new claims, reprocessed claims, overturned disputes, and appeals. The Claims Examiner plays a critical role in maintaining compliance, ensuring payment accuracy, and supporting members and Provider satisfaction.

Essential Duties And Responsibilities

• To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

• Key Responsibilities

  • Review, analyze, and process medical claims in accordance with Medicare and DSNP benefit structures, policies, and procedures.

  • Accurately adjudicate new day claims, ensuring proper application of benefits, coding edits, and pricing methodologies.

  • Reprocess claims resulting from overturned disputes and appeals, ensuring adjustments reflect updated determinations and regulatory requirements.

  • Evaluate and process claim disputes and reconsiderations, including those that result in overturn decisions requiring correction and re-adjudication.

  • Handle appeals-related claim adjustments, ensuring timely and accurate implementation of appeal outcomes.

  • Interpret provider contracts, fee schedules, and reimbursement methodologies to ensure correct payment.

  • Ensure compliance with CMS (Centers for Medicare & Medicaid Services), state regulations, and internal policies.

  • Identify and escalate complex claim issues, system errors, or potential compliance risks.

  • Maintain productivity and quality standards, meeting turnaround time requirements for all claim types.

  • Document claim processing activities clearly and accurately in system notes.

  • Collaborate with internal departments such as Provider Relations, Appeals & Grievances, and Configuration teams to resolve claim issues.

  • Participate in audits, quality reviews, and continuous improvement initiatives.

Qualifications And Education

• Required Qualifications

  • High school diploma or equivalent; associate or bachelor’s degree preferred.

  • Minimum of 2–4 years of claims processing experience in a managed care or health insurance environment.

  • Strong knowledge of Medicare and DSNP claims processing guidelines, including benefit application and coordination of benefits (COB).

  • Experience handling claims reprocessing, disputes, and appeals (including overturned cases).

  • Familiarity with CPT, HCPCS, and ICD-10 coding.

  • Understanding of provider contracts and reimbursement methodologies.

  • Strong analytical and problem-solving skills with high attention to detail.

  • Ability to manage multiple priorities in a fast-paced environment.

  • Proficiency in claims processing systems and Microsoft Office applications.

• Preferred Qualifications

  • Knowledge of CMS regulations and audit requirements.

  • Prior experience working with dual-eligible populations.

  • Medicare, Part C claims processing experience.

Core Competencies

• Accuracy and attention to detail

• Regulatory compliance awareness

• Critical thinking and decision-making

• Time management and productivity

• Communication and collaboration

WORKING CONDITIONS

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

• Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds.

• While performing the duties of this job, the employee is regularly required to talk or hear.

• The employee is frequently required to stand and walk.

• The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl.

• Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

• Duties accomplished at the end of the day/month.

• Attendance/punctuality.

• Compliance with Company regulations.

• Safety and Security.

• Quality of work.