medical 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

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

<div>
 ATHENS POSITION DETAILS
 <br/>
 <br/>
 <strong>
  Position Title:
  <br/>
  <br/>
 </strong>
 Assistant Claims Examiner - Flex
 <br/>
 <br/>
 <strong>
  Department:
  <br/>
  <br/>
 </strong>
 Workers&rsquo; Compensation
 <br/>
 <br/>
 <strong>
  Reports To:
  <br/>
  <br/>
 </strong>
 Claims Supervisor
 <br/>
 <br/>
 <strong>
  FLSA Status:
  <br/>
  <br/>
 </strong>
 Non-Exempt
 <br/>
 <br/>
 <strong>
  Job Grade:
  <br/>
  <br/>
 </strong>
 6
 <br/>
 <br/>
 <strong>
  Career Ladder:
  <br/>
  <br/>
 </strong>
 Next step in progression could include Future Medical Examiner or Claims Examiner Trainee
 <br/>
 <br/>
 <strong>
  ATHENS ADMINISTRATORS
  <br/>
  <br/>
 </strong>
 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!
 <br/>
 <br/>
 <strong>
  Position Summary
  <br/>
  <br/>
 </strong>
 Athens Administrators has an immediate need for an experienced Assistant Claims Examiner - Flex 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.
 <br/>
 <br/>
 The Assistant Claims Examiner - Flex 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 for a variety of teams and clients at Athens.
 <br/>
 <br/>
 <strong>
  Primary Responsibilities
  <br/>
  <br/>
 </strong>
 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:
 <br/>
 <br/>
 <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
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Essential Position Requirements
  <br/>
  <br/>
 </strong>
 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.
 <br/>
 <br/>
 <ul>
  <li>
   High School Diploma or equivalent (GED) required for all positions
  </li>
  <ul>
   <li>
    AA/AS or BA/BS preferred but not required
   </li>
  </ul>
  <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
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  APPLY WITH US
  <br/>
  <br/>
 </strong>
 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
 <br/>
 <br/>
 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.
 <br/>
 <br/>
 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.
 <br/>
 <br/>
 <strong>
  THANK YOU!
  <br/>
  <br/>
 </strong>
 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!
 <br/>
 <br/>
 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
 <strong>
  https://www.athensadmin.com/careers/why-work-here
 </strong>
</div>


Assistant Claims Examiner - Remote or Hybrid in CA

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

State of Tennessee

<div><p><b>Job Information</b>
</p><h3 class="jobSectionHeader"><b>State of Tennessee Job Information</b></h3><p><div><div><div>
Opening Date/Time</div><div> 05/05/2026 12:00AM Central Time</div></div><br>
<div><div>
Closing Date/Time</div><div> 05/18/2026 11:59PM Central Time</div></div><br>
<div><div>
Salary (Monthly)</div><div> $3,631.00 - $4,533.00</div></div><br>
<div><div>
Salary (Annually)</div><div> $43,572.00 - $54,396.00</div></div><br>
<div><div>
Job Type</div><div> Full-Time</div></div><br>
<div><div>
City, State Location</div><div> Nashville, TN</div></div><br>
<div><div>
Department</div><div> Human Services</div></div></div></p><p><b><br>
LOCATION OF (4) POSITION(S) TO BE FILLED: DEPARTMENT OF HUMAN SERVICES, DAVIDSON COUNTY</b><br>
<br>
<b>For more information, visit the link below:</b></p><p><b>
https://www.tn.gov/content/dam/tn/human-services/documents/HRC0019759_DISABILITY_CLAIMS_EXAMR1_Davidson_51826.pdf</b><br>
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<b>This is a remote position</b><br>
<br>
<b>This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position.</b></p><p><b>
Qualifications</b>
</p><p><b>Education and Experience:</b> Graduation from an accredited college or university with a bachelor's degree.</p><p><b>
Substitution of Experience for Education:</b> Full-time professional disability claims examination work may be substituted for the required education on a year-for-year basis.</p><p><b>
Necessary Special Qualifications:</b></p><ul><li>
Complete a federal background check in accordance with the Homeland Security Presidential Directive 12 (HSPD-12) for issuance of an HSPD-12 compliant Personal Identity Verification (PIV) credential card.</li><li>
After appointment, successfully complete (as indicated by an assessment at completion) a prescribed course of training offered by the Tennessee Department of Human Services.</li></ul><p><b>
Overview</b>
</p><p>This classification learns to perform disability determination work of average difficulty. An employee in this class is responsible for learning to determine adult medical eligibility for Social Security Disability, Supplemental Security Income or Medicaid benefits for initial claims in accordance with federal Social Security Administration guidelines. This classification performs responsibilities under direct supervision at the learning level. This class differs from the Disability Claims Examiner 2 in that an incumbent of the latter functions at the working level.</p><ul><li><i>An applicant appointed to this classification will be reclassified to a Disability Claims Examiner 2 after successful completion of a mandatory two-year training period; 'unacceptable' or 'needs improvement' performance ratings during the training period will result in automatic demotion or termination.</i></li></ul><p><b>
Responsibilities</b>
</p><p>ALL LISTED RESPONSIBILITIES WILL BE PERFORMED AT THE LEARNING LEVEL:</p><ul><li>
Determines adult medical eligibility for Social Security Disability, Supplemental Security Income or Medicaid benefits using medical, psychiatric, vocational, and educational data for initial claims in accordance with federal Social Security Administration guidelines.</li><li>
Routinely conducts telephone interviews with claimants and others to obtain and/or clarify information on applications. Determines jurisdiction and proper timeframe for requests of claimant records and obtains records from relevant treatment sources.</li><li>
Reviews and analyzes applications, medical assessments, medical records, and vocational assessments as needed for initial claims. Reviews prior decisions for accuracy and development of evidence and examines new allegations or evidence, redetermines medical eligibility, and issues reconsideration decisions.
</li><li>Documents case notes, appointments, and general correspondence for review and adjudication. Organizes and enters claimant documentary evidence and claim decisions into an electronic case management folder.</li><li>
Assesses claimant's medical conditions to identify impairments, onset issues, and limitations by reviewing medical records, statements, and other pertinent information to prepare a medical assessment.
</li><li>Confers with internal medical consultants and various other subject matter experts to ensure all aspects of disability claims are in accordance with federal guidelines. Selects, composes, and sends proper federal disability determination notices to claimants explaining medical and vocational decision issues to claimants and authorized representatives.</li><li>
Schedules/reschedules consultative examination appointments for claimants and notify claimants, third parties, attorneys of appointment time and date, and documents reasons for missed exams. Authorizes payments for examinations and claimant travel.</li><li>
Reviews claimant's work history to determine if claimant's past work description is adequate and contacts claimant by phone if additional work history is needed. Identifies and analyzes claimant's past relevant work by researching jobs and earnings reported to SSA and compare the claimant's residual capacity with the functional requirements of the claimant's past and other work.</li></ul><p><b>
Competencies (KSA's)</b>
</p><p><b>Competencies:</b></p><ul><li>
Customer Focus</li><li>
Resourcefulness</li><li>
Communicates Effectively</li><li>
Instills Trust</li><li>
Situational Adaptability</li></ul><p><b>
Knowledges:</b></p><ul><li>
Customer and Personal Service</li></ul><p><b>
Skills:</b></p><ul><li>
Active Learning and Listening</li><li>
Service Orientation</li><li>
Critical Thinking</li><li>
Judgment and Decision Making</li><li>
Time Management</li></ul><p><b>
Abilities:</b></p><ul><li>
Deductive Reasoning</li><li>
Inductive Reasoning</li><li>
Problem Sensitivity</li><li>
Written Comprehension</li></ul><p><b>
Tools &amp; Equipment</b>
</p><ul><li>General Office Equipment</li><li>
Computer/Laptop/Tablet</li><li>
Multifunction Printer (Print/Copy/Scan/Fax)</li><li>
Cell Phone</li></ul></div>

DISABILITY CLAIMS EXAMINER 1* - 05052026-77330

CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Position Summary</b></p><p>
Review and complete provider-solicited and unsolicited overpayment refunds and returned checks. Research, resolve, and adjudicate complex, sensitive, and/or specialized medical claims in accordance with claims-processing guidelines. Partner with key business functions, ensure accurate posting of overpayment refunds, reconcile discrepancies, and respond to internal and provider inquiries.</p><p><b>
Key Responsibilities</b></p><ul><li>
Process complex, non-routine provider refunds and returned checks</li><li>
Review and interpret contract language to validate overpayments and allocate refund checks appropriately</li><li>
Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply cost-containment measures to support claim adjudication</li><li>
Ensure compliance requirements are met and that payments/refunds follow company practices and procedures</li><li>
Perform claim rework calculations and adjustments across all dollar amounts for unsolicited overpayment refunds</li><li>
Follow through to completion on medical claim overpayments, underpayments, and other irregularities</li><li>
Respond to telephone and/or written inquiries related to pre-approvals/pre-authorizations, reconsiderations, and appeals</li><li>
Review assigned claims data mining work that may result in claim adjustments and complete resulting adjustments as appropriate</li><li>
Process medical claim adjustments on customer service platforms using technical and claims-processing expertise</li><li>
Provide overpayment refund training, mentoring, and job shadowing support for less experienced colleagues, as assigned</li><li>
Use available resource materials and tools to manage job responsibilities.</li></ul><p>
Handle customer service inquiries and issues assigned<br>
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<b>Required Qualifications</b></p><ul><li>
3+ years of medical claims processing experience</li><li>
2+ years of hands-on claim adjustments/rework experience</li><li>
2+ years in a production environment (volume + accuracy expectations)</li><li>
Demonstrated experience researching and resolving claim issues end-to-end</li><li>
Ability to interpret and apply guidelines related to eligibility, coverage, and benefits</li><li>
High attention to detail</li></ul><p><b><br>
Preferred Qualifications</b></p><ul><li>
Experience reviewing and researching overpayment refunds</li><li>
DG system claims processing experience</li><li>
Ability to manage multiple assignments accurately and efficiently</li><li>
Effective communication, organizational, and interpersonal skills</li><li>
Familiarity with overpayment recovery</li></ul><p><b><br>
Education</b></p><ul><li>
Associate degree or equivalent experience.</li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$18.50 - $42.35<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
We anticipate the application window for this opening will close on: 05/15/2026<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

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DISABILITY CLAIMS EXAMINER 1* - 05052026-77330

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