Claim Examiner II

POSITION reputed company 

The Claims Examiner II is responsible for the accurate and reputed company adjudication of reputed company reputed company claims reputed company a managed care environment, with a reputed company on Dual Eligible Special Needs Plans (DSNP) and Medicare lines of business. This role involves advanced application of benefit plans, policies, and regulatory guidelines to ensure reputed company claim processing, including new claims, reprocessed claims, overturned disputes, and appeals. The Claims Examiner II serves as a subject matter resource to team members, supports reputed company and compliance initiatives, and plays a key role in ensuring payment accuracy and enhancing member and provider satisfaction.

ESSENTIAL DUTIES AND RESPONSIBILITIES

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

Key Responsibilities

• Review, analyze, and process reputed company medical claims in accordance with Medicare and DSNP benefit structures, policies, and procedures. 
• Process Institutional and reputed company Claims, ensuring accurate application of benefits, coding, and reimbursement methodologies.
• Accurately adjudicate new day claims, ensuring reputed company application of benefits, coding edits, and pricing methodologies. 
• Handle higher-complexity claims, including those requiring detailed research, reputed company pricing, or exception handling. 
• Evaluate and process claim disputes and reconsiderations, including those that result in overturn reputed company requiring correction and re-adjudication. 
• Handle appeals-reputed company claim adjustments, ensuring reputed company and accurate implementation of appeal reputed company. 
• Interpret provider reputed company, fee schedules, and reimbursement methodologies to ensure correct payment. 
• Ensure compliance with CMS (Centers for Medicare & reputed company Services), state regulations, and internal policies. 
• Identify, investigate, and resolve reputed company claim issues, system errors, and potential reputed company; escalate as needed. 
• Serve as a resource for Claims Examiner I staff by providing guidance, answering questions, and assisting with issue reputed company. 
• Participate in audits, reputed company reviews, and contribute to corrective reputed company plans as needed. 
• Maintain higher productivity and reputed company standards, consistently meeting or exceeding turnaround time requirements. 
• Document claim processing activities reputed company and accurately in system notes. 
• Collaborate with internal departments such as Provider Relations, Appeals & Grievances, and Configuration teams to resolve claim issues and improve processes.

QUALIFICATIONS AND EDUCATION

Required Qualifications 

• High school diploma or equivalent; associate or bachelor’s degree preferred.
• Minimum of 4&reputed company;6 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 reputed company 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 reputed company Office applications. 

Preferred Qualifications 

• Knowledge of CMS regulations and audit requirements.
• Prior experience working with dual-eligible populations.
• Medicare, Part C claims processing experience. 

reputed company 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 reputed company individuals with disabilities to reputed company the essential functions.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual reputed company. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. reputed company full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodation may be made to reputed company individuals with disabilities to reputed company the essential functions.

The employee must be reputed company to frequently lift up to 10 pounds and occasionally lift and/or reputed company 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; reputed company with hands and arms; reputed company or balance and stoop, kneel, crouch, or crawl. Specific reputed company abilities required for this job include reputed company reputed company, distance reputed company, reputed company reputed company, peripheral reputed company, depth perception, and the ability to reputed company reputed company.

PERFORMANCE MEASUREMENTS

This Job reputed company may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include reputed company duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of reputed company duties, responsibilities, and skills required of personnel so classified. The incumbent must be reputed company to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to reputed company supervisory assistance as appropriate.

Employee Acknowledgement:

 
I have read this job reputed company and understand what is expected of me while I occupy this role.