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Claims Examiner III

The Claims Examiner III is a senior-level claims professional responsible for the accurate and timely adjudication of complex professional and institutional claims in accordance with regulatory requirements, contractual agreements, and internal policies. This role supports departmental workflow oversight, assists leadership with productivity and quality monitoring, and serves as a subject matter resource to team members to ensure operational excellence and compliance with CMS and organizational standards.

Key Responsibilities:

Review, analyze, and adjudicate professional and institutional claims, including high-dollar and complex cases.
Process Member Reimbursement claims in accordance with plan benefits and regulatory guidelines.
Ensure claims are processed accurately, timely, and in compliance with CMS regulations, state guidelines, and internal policies.
Assist the Claims Manager and/or Assistant Director in monitoring daily, weekly, and monthly workflow to meet production and quality targets.
Generate and analyze reports to track productivity, aging inventory, and pending items.
Provide guidance and clarification to team members regarding claims processing rules, contract interpretation, and system functionality.
Support the implementation and enforcement of departmental policies and procedures.
Collaborate with leadership to ensure production, accuracy, and turnaround time metrics are consistently met.
Communicate departmental goals, workflow strategies, and performance improvement initiatives to staff.
Promote a positive work environment that supports staff engagement, accountability, and teamwork.
Maximize system capabilities by ensuring proper utilization of claims processing tools and platforms.
Identify process improvement opportunities and escalate system or configuration issues as needed.
Perform additional duties as assigned.

Qualifications:

High School Diploma or GED
Minimum of 3+ years of experience as a Medical Claims Examiner.
Experience processing Medicare Advantage and/or managed care claims preferred.
Strong experience with contract interpretation and benefit application.
Working knowledge of CMS guidelines, Medicare regulations, and healthcare claims processing standards.
Strong analytical and problem-solving skills.
Proficiency in Windows-based systems and claims processing applications.

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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