Claims Examiner Senior \ 160

• The Claims Examiner Senior is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and desktops, as well as, ensuring compliance with federal regulations. This role works in conjunction with Business Configuration, Network Management, Provider Data, Complaints, Appeals and Grievances as well as other operational departments to ensure validation and quality assurance of claims processing.

• Meets expectations of the applicable Client Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines, and federal regulations. Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
• Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes. Process provider refunds, reconsiderations, and direct member reimbursements.
• Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication. Solve moderately complex claims and escalate issues to the Claims Team Lead, Supervisor or Manager. Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes. Serves as a resource to assist

Qualifications

• Experience processing and adjudicating medical claims in a healthcare, managed care, health insurance, or third-party administrator environment.
• Strong knowledge of CMS-1500 and CMS-1450/UB-04 claim forms.
• Understanding of medical terminology, provider billing practices, reimbursement methodologies, and claims processing guidelines.
• Experience handling claim adjustments, overpayment recovery, provider refunds, and reimbursement requests.
• Strong analytical, problem-solving, and research skills.
• Ability to manage multiple priorities while maintaining accuracy and attention to detail.
• Proficiency with claims processing systems and Microsoft Office applications.
• Excellent communication and collaboration skills.

Why Join Us?

• Join a mission-driven global health organization dedicated to improving healthcare outcomes through operational excellence, compliance, and exceptional service. This role offers the opportunity to work with experienced professionals while contributing to meaningful healthcare initiatives that impact members and providers worldwide.