Senior Claims Examiner

Verda Healthcare, Inc. is a Medicare Advantage Prescription Drug Plan (MAPD) organization committed to the idea that healthcare should be easily and equitably accessible to all, currently available in Texas and Arizona. Our mission is to ensure that underserved communities have access to health and wellness services and receive the support they need to live healthy lives, free of worry and full of joy. We are looking for a Senior Claims Examiner to join our growing company with many internal opportunities. Verda Healthcare is looking for people who value excellence, integrity, care, and innovation. As an employee, you'll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Position Overview

The Senior Claims Examiner is responsible for reviewing, analyzing, and adjudicating complex professional, institutional, inpatient, outpatient, Medicare Advantage, and delegated claims in accordance with CMS regulations, provider contracts, benefit plans, and company policies. This position serves as a subject-matter expert in claims processing, provider dispute resolution, payment integrity, and compliance-related activities, while supporting departmental productivity and quality goals.

Responsibilities

• Review and adjudicate complex medical claims in accordance with plan benefits, CMS guidelines, provider contracts, fee schedules, and reimbursement methodologies.
• Analyze claim documentation, medical records, authorizations, coordination of benefits, and eligibility information to determine appropriate claim disposition.
• Process adjustments, reopenings, corrected claims, appeals, and Provider Dispute Resolution (PDR) cases within regulatory turnaround times.
• Investigate payment discrepancies, duplicate payments, overpayments, underpayments, and reimbursement issues.
• Review provider contracts, fee schedules, DRG, APC, ASC, and other reimbursement methodologies to validate accurate payment.
• Maintain accuracy, production, quality, and timeliness standards established by the Claims Department.
• Document claim decisions, approvals, denials, adjustments, and overrides in the claims system.
• Research and respond to provider inquiries, claim escalations, and complex claim issues.
• Assist with audit requests, payment integrity reviews, compliance activities, and corrective action initiatives.
• Support training and mentoring of Claims Examiners and provide guidance on complex claims processing issues.
• Participate in special projects, system testing, implementation efforts, and operational improvement initiatives.

Knowledge, Skills, and Abilities

• Extensive knowledge of claims adjudication and payment methodologies.
• Strong understanding of Medicare, Medicaid, Commercial, and managed care claims.
• Experience with Provider Dispute Resolution (PDR), appeals, and payment integrity reviews.
• Knowledge of ICD-10, CPT, HCPCS, DRG, APC, and ASC reimbursement methodologies.
• Advanced analytical and problem-solving skills.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Excel, Outlook, Word, and claims management systems.

Requirements

• High School Diploma or GED required; associate or bachelor's degree preferred.
• Minimum 5 years of healthcare claims processing experience.
• Minimum 2 years of experience adjudicating Medicare Advantage claims preferred.
• Experience with professional, institutional, inpatient, outpatient, and delegated claims processing.
• Strong knowledge of CMS regulations, provider contracting, reimbursement methodologies, and claims operations.
• Ability to reliably commute or plan to relocate before starting work (Required).

Benefits

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance
• Dental Insurance
• Vision insurance
• Life insurance

Schedule

• Full-time onsite (100% in-office)
• Hours of operation: 9am – 6pm
• Standard business hours Monday to Friday/weekends as needed
• Occasional travel may be required for meetings and training sessions.

Pay

$28-32/hr. Actual compensation offered will be determined based on experience, qualifications, skills, internal equity (if available), and geographic location. This position may also be eligible for performance-based incentive compensation and benefits.

Physical Demands

• Regularly sit/walk at a workstation in an office or cubicle setting.
• Must occasionally lift and/or move up to 25-50 pounds.
• Other duties may be assigned in support of departmental goals.