insurance claims examiner

Ultimate Staffing

<div>
 <p>
  We are seeking an experienced Medical Claims Examiner to review, analyze, and adjudicate medical claims for accuracy, compliance, and medical necessity. The ideal candidate has strong working knowledge of
  <strong>
   ICD‑9 and ICD‑10 diagnosis coding
  </strong>
  and healthcare billing standards.
 </p>
 <p>
  <strong>
   Key Responsibilities:
  </strong>
 </p>
 <ul>
  <li>
   Review and process medical claims for completeness, accuracy, and compliance
  </li>
  <li>
   Apply ICD‑9 and ICD‑10 codes to evaluate claim validity
  </li>
  <li>
   Identify coding discrepancies, overpayments, and potential fraud or abuse
  </li>
  <li>
   Ensure claims adhere to payer policies, CMS guidelines, and regulatory requirements
  </li>
  <li>
   Document determinations and communicate findings as needed
  </li>
 </ul>
 <p>
  <strong>
   Qualifications:
  </strong>
 </p>
 <ul>
  <li>
   Proven experience as a Medical Claims Examiner or similar role
  </li>
  <li>
   Strong knowledge of
   <strong>
    ICD‑9 and ICD‑10 coding
   </strong>
  </li>
  <li>
   Familiarity with CPT, HCPCS, and medical billing guidelines
  </li>
  <li>
   Attention to detail and strong analytical skills
  </li>
  <li>
   Proficiency with claims processing systems and MS Office
  </li>
 </ul>
 <p>
  <strong>
   Preferred:
  </strong>
 </p>
 <ul>
  <li>
   CPC, CCS, or related certification
  </li>
  <li>
   Experience with Medicare, Medicaid, or commercial insurance claims
   <br/>
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <strong>
  Desired Skills and Experience
  <br/>
  <br/>
 </strong>
 We are seeking an experienced Medical Claims Examiner to review, analyze, and adjudicate medical claims for accuracy, compliance, and medical necessity. The ideal candidate has strong working knowledge of ICD‑9 and ICD‑10 diagnosis coding and healthcare billing standards.
 <br/>
 Key Responsibilities:
 <br/>
 <br/>
 Review and process medical claims for completeness, accuracy, and compliance
 <br/>
 Apply ICD‑9 and ICD‑10 codes to evaluate claim validity
 <br/>
 Identify coding discrepancies, overpayments, and potential fraud or abuse
 <br/>
 Ensure claims adhere to payer policies, CMS guidelines, and regulatory requirements
 <br/>
 Document determinations and communicate findings as needed
 <br/>
 <br/>
 Qualifications:
 <br/>
 <br/>
 Proven experience as a Medical Claims Examiner or similar role
 <br/>
 Strong knowledge of ICD‑9 and ICD‑10 coding
 <br/>
 Familiarity with CPT, HCPCS, and medical billing guidelines
 <br/>
 Attention to detail and strong analytical skills
 <br/>
 Proficiency with claims processing systems and MS Office
 <br/>
 <br/>
 Preferred:
 <br/>
 <br/>
 CPC, CCS, or related certification
 <br/>
 Experience with Medicare, Medicaid, or commercial insurance claims
 <br/>
 <br/>
 <p>
  <em>
   All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.
  </em>
 </p>
</div>


Medical Claims Examiner

Benecard Services Inc.

<p></p><div><div><div><div><div><div>The Claims Examiner &ndash; Vision Insurance is a key contributor within the Claims Department, responsible for accurately adjudicating vision and eye care claims in compliance with Medicaid, Medicare, and commercial payer guidelines. This role supports operational excellence by ensuring timely payments, regulatory compliance, and high-quality service to providers and internal stakeholders. The Claims Examiner plays an active role in meeting departmental performance metrics and supporting audits, reporting, and workflow oversight.</div><div></div><div><br>
This is a fully on-site role, and employees are expected to report to the Clifton, New Jersey office five days per week and is a Union position.</div><div></div><div><b><br>
Key Responsibilities</b></div><ul><li>
Review, evaluate, and adjudicate vision and eye care insurance claims in accordance with payer guidelines, including Medicaid, Medicare, and Coordination of Benefits (COB) rules</li><li>
Process complex or high-dollar claims requiring supervisory overrides</li><li>
Distribute daily claim workloads and support operational workflow efficiency</li><li>
Prepare and maintain documentation for internal and external audits</li><li>
Ensure compliance with prompt pay regulations and timely filing requirements</li><li>
Research and resolve rejected, denied, or pending claims, including billing corrections and resubmissions</li><li>
Analyze remittance advice (EOBs/ERAs) and communicate findings as needed</li><li>
Support monthly claims reporting and departmental performance tracking</li><li>
Collaborate with leadership to meet monthly productivity and accuracy goals</li><li>
Respond promptly and professionally to internal and external communications</li><li>
Perform additional duties as assigned to support claims operations and leadership initiatives</li></ul><div></div><div><b><br>
Required Qualifications:</b></div><ul><li>
5+ years of experience adjudicating and processing healthcare claims, preferably in vision insurance or eye care</li><li>
Strong knowledge of Medicaid and Medicare claim processing</li><li>
Proficiency with CPT, ICD-10, HCPCS codes, and modifiers, including billing and coding edits</li><li>
Solid understanding of Third-Party Liability (TPL) and Coordination of Benefits (COB) rules</li><li>
Experience with electronic claims submission, clearinghouses, and billing resubmission processes</li><li>
In-depth knowledge of HCFA-1500 (CMS-1500) and electronic billing standards</li><li>
Familiarity with appeals and reconsideration processes for government payers</li><li>
Experience researching and resolving claim denials and timely filing issues</li><li>
Working knowledge of AS400 or similar claims processing systems</li><li>
Intermediate to advanced Microsoft Office skills, with emphasis on Excel</li><li>
Strong attention to detail, analytical skills, and ability to manage deadlines in a high-volume environment</li></ul><div></div><div><b><br>
Preferred Qualifications:</b></div><ul><li>
Previous leadership experience would be preferred</li><li>
Certified Professional Coder (CPC/CBC) and/or Certified Professional Biller (CPB)</li><li>
Prior experience in vision plans, optometry, ophthalmology, or eye care billing</li><li>
Experience supporting or participating in claims audits or compliance reviews</li></ul><div></div><div><b><br>
Why Join Us?</b></div><ul><li>
Be part of a collaborative claim&rsquo;s leadership-focused environment</li><li>
Opportunity to specialize in eye care and vision insurance claims</li><li>
Role offers stability, growth, and exposure to complex adjudication and compliance work</li></ul><p></p><p><br>
National Vision Administrators</p><p>
For over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health &amp; Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey.</p><p>
Website: http://www.e-nva.com</p><p>
We are an equal opportunity employer</p></div></div></div></div><br>
Monday - Friday 8:30am - 5:00pm</div>

Claims Examiner

State of Utah

<p></p><div><p><b>Claims Examiner I, Career Service Exempt</b></p><p><b>
FT / PT Status &ndash; </b>Full-Time<br>
<b>Salary &ndash; </b>$18.00 - $31.61 Hourly Wage
<br>
<b>Remote Work / In-Office &ndash; </b>Hybrid (After ample training, may qualify for hybrid/remote)<br>
<br>
<b>Recruiter &ndash; </b>Liz Vander Linden | evander@utah.gov | 801-957-7232<br>
<b>Application Deadline &ndash; </b>4/26/2026</p><p></p><p><b><br>
Key Responsibilities</b></p><p><br>
The Utah Unclaimed Property Division seeks a full-time Claims Examiner I, Career Service Exempt to join our committed, creative, and enthusiastic team. We return tens of millions of dollars of unclaimed property to rightful owners every year.<br>
Our next Claims Examiner I will assist many Utahns in recovering their lost money. Some claims are very easy and others are like solving a huge puzzle to determine who is the rightful owner. Look us up at: mycash.utah.gov.</p><p>
Please note this is an entry level position.</p><p>
Do you:</p><ul><li>
Strive for accuracy and precision?</li><li>
Perform best with clear direction, rules, and structure?</li><li>
Enjoy being a resource of knowledge &amp; information for others?</li><li>
Embrace opportunities to work independently?</li><li>
Relish Solving problems and pivoting to meet the current need?</li><li>
Avoid chaos and drama and instead focus on facts and data?</li><li>
Prefer to work alone on tasks rather than in a group?</li><li>
Are you a skeptical person who requires volumes of information before forming a firm opinion?</li><li>
Find that your communication style is more informative and factual than socially oriented?</li><li>
Possess a natural sense of urgency &amp; move quickly between tasks?</li><li>
Communicate directly, factually &amp; in a no-nonsense manner?</li><li>
Desire change, new challenges, &amp; variety over routine?</li><li>
Perform better in an orderly work environment that is free of clutter?</li></ul><p>
If this is you, we should talk.</p><p>
First, go to this page: https://go.cultureindex.com/p/n6hu69Wz715hd3rCdf1H to take a quick 8-10 minute survey and attach your resume.</p><p>
If we determine that you are a great fit, we will follow up with more information and a full description of responsibilities and benefits.</p><p></p><p><b><br>
About the Role</b></p><p><b>
Location</b> &ndash;
<br>
168 North 1950 West, Suite 102<br>
Salt Lake City, UT, 84116<br>
United States
<br>
<b>Background Check Required</b> &ndash; No<br>
<b>Drug Test Required</b> &ndash; No
<br>
<b>Schedule Code</b> &ndash; AC - Employees in Offices of Elected Officials</p><p><b>
Schedule: Monday - Friday 8 hour shift</b></p><p><b>
Why You Should Join Our Team</b><br>
In Utah, we believe hard work is important, but balance is essential. Finding work/life balance is a vital element to our culture. To find out more about WHY Utah, click here. Other benefits may include:</p><ul><li><b>
Job Stability: </b>Enjoy the security and reliability of employment within a well-established organization.</li><li><b>
Career Growth:</b><b> </b>Develop valuable skills and gain opportunities for leadership within a large organization.</li><li><b>
Meaningful Work: </b>Contribute to an important service that benefits the community and supports organizational goals.</li><li><b>
Supportive Work Environment:</b><b> </b>Be part of a team that values cooperation, strong work ethics, and mutual support.</li></ul><p><b>
The Agency</b><br>
Millions of dollars in lost or unclaimed money are turned over to the State of Utah every year. This money comes from places like dormant bank accounts, old stock certificates, and uncollected insurance checks. This is the official government website for managing and returning this unclaimed property to the residents of Utah.</p><p><b>
EEO Statement</b><br>
The State of Utah is committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. For accommodations, please contact (801) 957-9390.</p></div><div></div>

Claims Examiner I, Career Service Exempt

Athens Administrators

<div><div><b>ATHENS POSITION DETAILS</b></div>
<div></div><div><div><div><div><div><b>Position Title:</b></div>
</div><div><div>Assistant Claims Examiner</div><br>
</div></div><br>
<div><div><div><b>Department:</b></div>
</div><div><div>Workers&rsquo; Compensation</div><br>
</div></div><br>
<div><div><div><b>Reports To:</b></div>
</div><div><div>Claims Supervisor</div><br>
</div></div><br>
<div><div><div><b>FLSA Status:</b></div>
</div><div><div>Non-Exempt</div><br>
</div></div><br>
<div><div><div><b>Job Grade:</b></div>
</div><div><div>6</div><br>
</div></div><br>
<div><div><div><b>Career Ladder:
</b></div></div><div><div>Next step in progression could include Future Medical Examiner or Claims Examiner Trainee</div>
</div></div><br>
</div></div><div></div><div><b>ATHENS ADMINISTRATORS</b></div>
<div>Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a &ldquo;Best Place to Work.&rdquo; Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family-owned company in Workers' Compensation, Property &amp; Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today!</div>
<div></div><div><b>POSITION SUMMARY</b></div>
<div>Athens Administrators has an immediate need for an experienced Assistant Claims Examiner to support our Workers&rsquo; Compensation department and can be located anywhere in the state of California, however, employees who live less than 26 miles from the Concord, CA or Orange, CA offices are required to work once a week in the office on a day determined by their supervisor between Tuesday &ndash; Thursday. The remaining days can be worked remotely if technical requirements are met, and the employee resides in California. Athens offices are open for business Monday-Friday from 7:30 a.m. to 5:30 p.m. local time. The schedule for this position is Monday-Friday at 37.5 hours a week with the option of a flex schedule. The Assistant Claims Examiner will provide clerical and technical assistance to Senior Claims Examiners and administer Medical Only claims, ensuring timely processing of claims and payment of benefits, managing, and directing medical treatment, and setting reserves.</div>
<div></div><div><b>PRIMARY RESPONSIBILITIES</b></div>
<div>Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:</div>
<div></div><ul><li>Process new claims in compliance with client&rsquo;s Service Agreement</li>
<li>Issue all indemnity payments and awards on time</li>
<li>Process all approved provider bills timely</li>
<li>Prepare objection letters to providers for medical bills; delayed, denied, lacking reports.</li>
<li>Answer questions over the phone from medical providers regarding bills</li>
<li>Contact treating physician for disability status</li>
<li>Contact employer for return-to-work status or availability of modified work.</li>
<li>Contact injured worker at initial set up</li>
<li>Send DWC notices timely</li>
<li>Issue SJDB Notices timely</li>
<li>Request Job Description from Employer</li>
<li>Handle Medical Only claim files</li>
<li>Calculate wage statements and adjust disability rates as required</li>
<li>Keep diary for all delay dates and indemnity payments</li>
<li>Documents file activity on computer</li>
<li>Update information on computer, i.e., address changes, etc.</li>
<li>Schedule appointments for AME, QME evaluations</li>
<li>Send appointment letters, issue TD/mileage, send medical file</li>
<li>Schedule interpreter for appointments, depositions, etc.</li>
<li>Request Employer&rsquo;s Report, DWC-1, Doctor&rsquo;s First Report if needed</li>
<li>Verify mileage and dates of treatment for reimbursement to claimant</li>
<li>Subpoena records</li>
<li>File and serve documents on attorneys, WCAB, doctors</li>
<li>Serve PTP&rsquo;s with medical file and Duties of Treating Physician (9785)</li>
<li>Request PD ratings from DEU</li>
<li>Draft Stipulated Awards and C&amp;R&rsquo;s</li>
<li>Submit C&amp;R, Stipulated Awards to WCAB for approval with documentation</li>
<li>Process checks &ndash; stop payment, cancellations, void, journal payments</li>
<li>Handle telephone calls for examiner as needed</li>
<li>Complete penalty calculations and prepare penalty worksheets</li>
<li>Complete MPN, HCO and/or EDI coding</li>
<li>Complete referrals to investigators</li>
<li>Complete preparation of documents for overnight delivery</li>
<li>Work collaboratively with Senior Claims Examiners, Nurse Case Managers, and other Assistant Claims Examiners</li>
<li>Contact with clients, injured workers, attorneys, doctors, vendors, and other parties</li>
<li>Provide updates of claims status to Senior Claims Examiners and Athens management</li>
<li>Prepare professional, well written correspondence and other communications</li>
</ul>
<div></div><div><b>ESSENTIAL POSITION REQUIREMENTS
</b></div><div>The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.</div>
<ul><li>High School Diploma or equivalent (GED) required for all positions
<ul><li>AA/AS or BA/BS preferred but not required</li>
</ul></li><li>2+ years&rsquo; Claims Assistant experience supporting a workers compensation examiner or team preferred</li>
<li>Medical Only Adjuster designation required</li>
<li>Continuing hours must be current</li>
<li>Mathematical calculating skills</li>
<li>Completion of IEA or equivalent courses</li>
<li>Administrators Certificate from Self-Insurance Plans preferred</li>
<li>Knowledge of workers compensation laws, policies, and procedures</li>
<li>Understanding of medical and legal terminology</li>
<li>Must demonstrate accuracy and thoroughness in work product</li>
<li>Ability to sit for prolonged periods of time</li>
<li>Well-developed verbal and written communication skills with strong attention to detail</li>
<li>Excellent organizational skills and ability to multi-task</li>
<li>Ability to type quickly, accurately and for prolonged periods</li>
<li>Proficient in Microsoft Office Suite</li>
<li>Ability to learn additional computer programs</li>
<li>Reasoning ability, including problem-solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues, and make appropriate recommendations and solutions for resolution</li>
<li>Ability to be trustworthy, dependable, and team-oriented for fellow employees and the organization</li>
<li>Seeks to include innovative strategies and methods to provide a high level of commitment to service and results</li>
<li>Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner</li>
<li>Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor</li>
<li>Athens&rsquo; operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.</li>
<li>Must be able to reliably commute to meetings and events as required by this position</li>
</ul><div><b>APPLY WITH US</b></div>
<div>We look forward to learning about YOU! If you believe in our core values of honesty and integrity, a commitment to service and results, and a caring family culture, we invite you to apply with us. Please submit your resume and application directly through our website at http://www.athensadmin.com/careers/job-openings Feel free to include a cover letter if you&rsquo;d like to share any other details. All applications received are reviewed by our in-house Corporate Recruitment team. The Company will consider qualified applicants with arrest or conviction records in accordance with the Los Angeles Fair Chance Ordinance for Employers and the California Fair Chance Act. Applicants can learn more about the Los Angeles County Fair Chance Act, including their rights, by clicking on the following link: https://dcba.lacounty.gov/wp-content/uploads/2024/08/FCOE-Official-Notice-Eng-Final-8.30.2024.pdf</div>
<div></div><div>This description portrays in general terms the type and levels of work performed and is not intended to be all-inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self-education, prior experience, or on-the-job training.</div>
<div></div><div>Athens Administrators is an Equal Opportunity/ Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability, or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.</div>
<div></div><div><b>THANK YOU!</b></div>
<div>We look forward to reviewing your information. We understand that applying for jobs may not be the most enjoyable task, so we genuinely appreciate the time you've dedicated. Don&rsquo;t forget to check out our website at www.athensadmin.com as well as our LinkedIn, Glassdoor, and Facebook pages!</div>
<div></div><div>Athens Administrators is dedicated to fair and equitable compensation for our employees that is both competitive and reflective of the market. The estimated rate of pay can vary depending on skills, knowledge, abilities, location, labor market trends, experience, education including applicable licenses &amp; certifications, etc. Our ranges may be modified at any time. In addition, eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments. We offer a variety of benefit plans including Medical, Vision, Dental, Life and AD&amp;D, Long Term Care, Critical Care, Accidental, Hospital Indemnity, HSA &amp; FSA options, 401k (and Roth), Company-Paid STD &amp; LTD and more! Further information about our comprehensive benefits package may be found on our website at <b>https://www.athensadmin.com/careers/why-work-here</b></div></div>

Assistant Claims Examiner

Kinsale Insurance Company

<div><p>As a Claims Examiner, you will play a key role in managing casualty claims from investigation through resolution. This position combines analytical thinking, decision-making, and negotiation to ensure fair and timely claim outcomes. You&rsquo;ll work closely with experienced claims professionals and legal partners while handling a diverse portfolio, including litigated claims. This is a great opportunity to grow your expertise in a fast-paced, team-oriented environment that values learning and career development.</p>
<h4 class="jobSectionHeader"><b>
What You&rsquo;ll Do</b></h4>
<ul><li>Manage a variety of casualty claims under the guidance of a Claims Supervisor</li>
<li>Conduct and coordinate investigations across all phases of the claims process</li>
<li>Evaluate liability and exposure to develop effective resolution strategies</li>
<li>Analyze policy coverage, make determinations, and draft clear coverage correspondence</li>
<li>Communicate claim decisions and updates with policyholders and key stakeholders</li>
<li>Maintain accurate, detailed, and timely documentation within claim files</li>
<li>Oversee litigated claims by appointing and managing defense counsel</li>
<li>Drive claims and litigation toward efficient and fair resolution</li>
<li>Participate in mediations, settlement discussions, and trials as needed</li>
</ul><h4 class="jobSectionHeader"><b>What You Bring</b></h4>
<ul><li>Bachelor&rsquo;s degree in Business, Risk Management, or a related field</li>
<li>2+ years of experience handling commercial general liability claims involving bodily injury and property damage</li>
<li>Strong analytical, problem-solving, and decision-making skills</li>
<li>Excellent written and verbal communication abilities</li>
<li>Experience managing litigated claims and working with defense counsel</li>
<li>Ability to analyze medical records, contracts (including risk transfer provisions), property damage estimates, and litigation documents</li>
<li>Strong organizational and time management skills with the ability to multitask</li>
<li>Proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint)</li>
<li>A collaborative mindset with strong negotiation skills</li>
</ul>
<p><i>Adjuster licenses or industry designations are a plus.</i></p>
<h4 class="jobSectionHeader"><b>
Why You&rsquo;ll Love Working at Kinsale</b></h4>
<ul><li><b>Competitive Pay &amp; Bonus Opportunities</b> &ndash; Rewarding performance and initiative.</li>
<li><b>Comprehensive Benefits</b> &ndash; Health, dental, and vision insurance with up to $3,600 (individual) or $6,800 (family) in HSA contributions per year.</li>
<li><b>Work-Life Balance</b> &ndash; Generous paid time off including 22 days of PTO and 10 paid company holidays.</li>
<li><b>Career Growth</b> &ndash; Clear promotion paths, mentorship, and ongoing professional development.</li>
<li><b>Retirement &amp; Security</b> &ndash; Up to 6% matching 401(k) contributions on base salary and bonus, standard life insurance, and disability coverage.</li>
<li><b>Continuous Learning</b> &ndash; Annual $3,000 reimbursement for educational training and certifications.</li>
</ul><h4 class="jobSectionHeader"><b>Integrity &amp; Responsibility</b></h4>
<p>
Kinsale values strong financial responsibility. A credit check may be conducted as part of the selection process for roles that require sound judgment and trustworthiness.</p>
<h4 class="jobSectionHeader"><b>
Ready to Apply?</b></h4>
<p>
If you&rsquo;re a detail-oriented claims professional who thrives in a collaborative and fast-paced environment, this is your opportunity to grow your career with Kinsale Insurance. Join a company that values innovation, excellence, and continuous learning.</p>
<p><b>
Apply today and take the next step in your career!</b></p></div>

DOCTORS HEALTHCARE PLANS, INC.

<div><p>The<b> Claims Examiner III </b>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.<br>
<br>
<b>Key Responsibilities:</b></p><div><ul><li>
Review, analyze, and adjudicate professional and institutional claims, including high-dollar and complex cases.</li><li>
Process Member Reimbursement claims in accordance with plan benefits and regulatory guidelines.</li><li>
Ensure claims are processed accurately, timely, and in compliance with CMS regulations, state guidelines, and internal policies.</li><li>
Assist the Claims Manager and/or Assistant Director in monitoring daily, weekly, and monthly workflow to meet production and quality targets.</li><li>
Generate and analyze reports to track productivity, aging inventory, and pending items.</li><li>
Provide guidance and clarification to team members regarding claims processing rules, contract interpretation, and system functionality.</li><li>
Support the implementation and enforcement of departmental policies and procedures.</li><li>
Collaborate with leadership to ensure production, accuracy, and turnaround time metrics are consistently met.</li><li>
Communicate departmental goals, workflow strategies, and performance improvement initiatives to staff.</li><li>
Promote a positive work environment that supports staff engagement, accountability, and teamwork.</li><li>
Maximize system capabilities by ensuring proper utilization of claims processing tools and platforms.</li><li>
Identify process improvement opportunities and escalate system or configuration issues as needed.</li><li>
Perform additional duties as assigned.</li></ul><div><b>
Qualifications:</b></div></div><ul><li>
High School Diploma or GED</li><li>
Minimum of 3+ years of experience as a Medical Claims Examiner.</li><li>
Experience processing Medicare Advantage and/or managed care claims preferred.</li><li>
Strong experience with contract interpretation and benefit application.</li><li>
Working knowledge of CMS guidelines, Medicare regulations, and healthcare claims processing standards.</li><li>
Strong analytical and problem-solving skills.</li><li>
Proficiency in Windows-based systems and claims processing applications.<br>
</li></ul><div><i>
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.</i></div><p><i>
No Third Party Agencies or Submissions Will Be Accepted.</i><br>
<br>
<i>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</i><br>
<br>
<i>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.</i></p><p>
</p><p>3hOLMnYaLt</p></div>

Claims Examiner III

Sedgwick

<div><p>By joining Sedgwick, you'll be part of something truly meaningful. It&rsquo;s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there&rsquo;s no limit to what you can achieve.
</p><p></p><p>Newsweek Recognizes Sedgwick as America&rsquo;s Greatest Workplaces National Top Companies
</p><p>Certified as a Great Place to Work&reg;
</p><p>Fortune Best Workplaces in Financial Services &amp; Insurance
</p><p></p>Claims Examiner - Workers Compensation I Midwest Jurisdictions
<p></p><div><p>Are you looking for an opportunity to join a global industry leader where you can bring your big ideas to help solve problems for some of the world&rsquo;s best brands?
</p><ul><li>Apply your workers compensation examiner knowledge and experience to adjudicate complex customer claims in the context of an energetic culture.
</li><li>Deliver innovative customer-facing solutions to clients who represent virtually every industry and comprise some of the world&rsquo;s most respected organizations.
</li><li>Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service.
</li><li>Leverage Sedgwick&rsquo;s broad, global network of experts to both learn from and to share your insights.
</li><li>Take advantage of a variety of professional development opportunities that help you perform your best work and grow your career.
</li><li>Enjoy flexibility and autonomy in your daily work, your location, and your career path.
</li><li>Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs.
</li></ul><p></p><p><b>PRIMARY PURPOSE OF THE ROLE: </b>We are looking for driven individuals that embody our caring counts model and core values that include empathy, accountability, collaboration, growth, and inclusion.
</p><p></p><p><b>ARE YOU AN IDEAL CANDIDATE? </b>To analyze workers compensation claims on behalf of our valued clients to determine benefits due, while ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements.
</p><p></p><p><b>ESSENTIAL RESPONSIBLITIES MAY INCLUDE
</b></p><ul><li>Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim.
</li><li>Negotiating settlement of claims within designated authority.
</li><li>Communicating claim activity and processing with the claimant and the client.
</li><li>Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner.
</li></ul><p></p><p><b>QUALIFICATIONS
</b></p><p>Education &amp; Licensing: 5 years of claims management experience or equivalent combination of education and experience required.
</p><ul><li>High School Diploma or GED required. Bachelor's degree from an accredited college or university preferred.
</li><li>Professional certification as applicable to line of business preferred.
</li></ul><p></p><p>Licensing / Jurisdiction Knowledge: <b>IL, MN, IN, WI
</b></p><p></p><p><b>TAKING CARE OF YOU
</b></p><ul><li>Flexible work schedule.
</li><li>Referral incentive program.
</li><li>Opportunity to work in an agile environment.
</li><li>Career development and promotional growth opportunities.
</li><li>A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one.
</li></ul><p></p><p>Work environment requirements include &ndash;
<br>
Physical: Computer keyboarding
<br>
Auditory/visual: Hearing, vision and talking
<br>
Mental: Clear and conceptual thinking ability; excellent judgement and discretion; ability to meet deadlines.
</p><p></p><p><i>As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $63,404 - $89,000/yr. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. Always accepting applications.
</i></p></div><p></p><p>Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
</p><p></p><h2 class="jobSectionHeader"><b>If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.</b></h2></div>

Claims Examiner - Workers Compensation I Midwest Jurisdictions

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Claims Examiner - Workers Compensation I Midwest Jurisdictions