Claims Examiner III

Summary

Join Gravie as a Claims Examiner III and support, review, and adjudicate claims using our best-in-class system. As a subject matter expert, you will evaluate, research, and analyze claim submissions, adhering to national guidelines. You will also mentor team members, contribute to process development, and participate in special projects. Responsibilities include processing claims, resolving issues, conducting audits, and facilitating training. You will collaborate with various teams, including QA, to improve departmental outcomes and maintain KPIs. Demonstrate expertise in complex claim scenarios and produce clear documentation.

Requirements

• High School Diploma
• 6 + years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment
• Strong knowledge of CPT/HCPC and ICD-10 code rules
• Ability to set priorities, manage time and work independently
• Basic proficiency using Windows based other computer applications
• Functional comfort with Zoom, Microsoft Teams, or Google Meets
• General knowledge of CMS claims submission regulations
• Demonstrated success getting results through collaboration
• Excellent facilitation and transferable knowledge skills communicating effectively on complex concepts
• Proven ability to develop and implement medical claims processes
• Experience in managing and assigning claims inventory

Responsibilities

• Support team discussions and aid in team claims issue resolution
• Support Claims Operations in testing claim scenarios, system configuration and system upgrades
• Support team members in reaching their full potential by providing coaching, sharing expertise, best practices, offering constructive feedback for improvement, and celebrating accomplishments
• Process claims within designated queues and adjudicate them in accordance with established claims policies and guidelines
• Act as a liaison between team members and upper management to relay feedback, updates, and concerns
• Review pended claim queues and apply expertise to resolve issues by collaborating with members of Claims Operations
• Conduct periodic reviews of claims and audit processes to identify opportunities for improving departmental outcomes
• Continually meet Key Performance Indicators (KPI’s) and quality expectations laid out by the department
• Play a key role in the development of departmental workflows
• Facilitate department-specific training, new hire training and ongoing education to support team development and knowledge retention
• Collaborate with QA team to determine necessary updates to department procedures to improve overall Financial and Payment accuracy
• Foster a collaborative team environment by actively participating in team discussions, offering support to colleagues, and maintaining a positive and solution-oriented attitude
• Demonstrate a thorough understanding of complex claim scenarios and the ability to produce clear, concise written documentation outlining claim processing procedures in accordance with Summary Plan Descriptions (SPDs). Areas of expertise include, but are not limited to: Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing

Preferred Qualifications

• Medical Coding experience/ Certification
• Medical Billing experience
• Understanding of provider data
• Previous start-up company experience
• Degree in Healthcare Administration or similar field
• Previous experience using Javelina processing system

Benefits

• Standard health and wellness benefits
• Alternative medicine coverage
• Flexible PTO
• Up to 16 weeks paid parental leave
• Paid holidays
• A 401k program
• Cell phone reimbursement
• Transportation perks
• Education reimbursement
• 1 week of paid paw-ternity leave