Medical Claims Examiner II

About the role

As Gravie looks to continue its member-centric approach to healthcare, the Medical Claims Examiner II will support, review and adjudicate claims in our best in class claim system. They are a subject matter expert capable of thoroughly evaluating, researching, and analyzing claim submissions with a solid knowledge of national claims guidelines. In addition to owning a high-volume, high-complexity caseload, this role may serve as a go-to resource for other Examiners, contribute to training and special projects, and support leadership with inventory management, process development, and auditing.

Responsibilities

• Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures
• Process complex claim scenarios in accordance with Summary Plan Descriptions (SPDs). Areas of expertise include, but are not limited to: Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing
• Review claims queues and provide expertise to address nuances with appropriate parties
• Serve as a go-to resource for other Examiners, answering questions and helping resolve claims issues as they arise
• Continually meet department metrics and quality standards set forth by leadership
• Communicate complex claims issues clearly through documentation and direct communication
• Provide ongoing feedback to leadership on workflow gaps, process improvements, system enhancements, and training needs
• Support leadership with special projects as assigned, including inventory management, process development, and auditing

Qualifications

• High School Diploma
• 4+ years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment
• Strong knowledge of CPT/HCPC and ICD-10 code rules
• Ability to set priorities, manage time and work independently
• Functional comfort with Zoom, Microsoft Teams, or Google Meets
• General knowledge of CMS claims submission regulations
• Strong collaboration and communication skills within a team setting

Preferred qualifications

• Medical Coding experience/certification
• Medical Billing experience
• Understanding of provider data
• Degree in Healthcare Administration or similar field
• Previous experience using Javelina processing system
• Experience with training and ability to create processes/procedure documentation
• Previous start-up company experience

About Gravie

• We know healthcare. Our company was founded and is still led by industry veterans who have started and grown several market-leading companies in the space
• We have raised money from top tier investors who share the same long-term vision as we do of building an industry defining company that will endure over the long run. We are well capitalized
• Our clients love us. Customer satisfaction rates among employees using Gravie health plans consistently rank above 80% – nearly 40 points above the industry average
• Our culture is unique. We tend to be non-hierarchical, merit-driven, opinionated but kind people who thrive working in a high-performance, fast-paced environment. People at Gravie care deeply about making a positive impact in the lives of the people we serve

Benefits

• Standard health and wellness benefits
• Alternative medicine coverage
• Flexible PTO
• Up to 16 weeks paid parental leave
• Paid holidays
• 401k program
• Transportation perks
• Education reimbursement
• 2 days of paid paw-ternity leave