Senior Claims Examiner

About the Role

The Senior Claims Examiner processes large-dollar and complex health care claims, adjustments, and contracts requiring a high degree of accuracy. This role involves reviewing, analyzing, and researching complex claims to identify discrepancies, verify pricing, confirm prior authorizations, and ensure proper payment. The incumbent assists in resolving escalated issues, mentors team members, leads training, and serves as a subject matter expert in process improvement activities.

Responsibilities

• Adjudicate all claim types, including Dental, Vision, Medical (inpatient/outpatient), Blue Card, physician claims, In/Out of Network claims, Medicaid reclamation (HIPD), FSA, foreign claims, outpatient lab/radiology, accident, Third-Party Liability (TPL), and Medicare Secondary Payer (MSP) by calculating benefits to approve or deny based on SPD.
• Research written/verbal queries from providers, members, or internal departments to determine appropriate claim actions and process corrections.
• Analyze patient and medical records to identify instances requiring investigation for claim benefits, pricing, prior authorization, or coordination of benefits, and process claims accordingly.
• Examine claim files for accuracy, make adjustments, verify eligibility/medical authorization, and contact healthcare providers for necessary documentation.
• Review and release high-dollar or complex claims; compile records for Enhanced Claim Review (ECR) through vendor portals (e.g., Valenz, Occunet, Anthem).
• Research, resolve, and respond to correspondence and escalated communications (Ops Connect) related to electronic and paper claims.
• Review reports (e.g., daily/pend reports, weekly cumulative pending) to ensure timely adjudication within corporate cycle times.
• Assist leadership in improving turnaround times, processes, or staff training by identifying errors through data analysis and auditing.
• Ensure legal compliance with company policies, state/federal insurance regulations, and assist the Legal Department with member/provider appeals or disputes.
• Resolve benefit and eligibility issues within claims processing and ERISA guidelines while maintaining productivity and quality standards.
• Maintain a HIPAA-compliant workstation and protect confidential client/enrollee data.
• Perform regulatory operations research to support guideline/SOP/workflow development and provide recommendations for improvements.
• Analyze problems, data, or text, considering multiple perspectives before making decisions.
• Partner with peers and external departments to document, analyze, and implement functional requirements, identifying gaps and alternative solutions.
• Act as a Subject Matter Expert (SME) for training, claims determinations, IT testing, mentorship, and special projects.
• Initiate and execute Work Instructions to enhance claim documentation.
• Maintain internet speed of 40MB download/10MB upload with a wired Ethernet connection.
• Maintain safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• Perform all other duties as assigned to support company competitiveness and profitability.