Medical Claims Examiner II

Summary

Join Gravie as a Medical Claims Examiner II and support, review, and adjudicate claims using our best-in-class system. As a subject matter expert, you will thoroughly evaluate and analyze claim submissions, adhering to national guidelines. You will also play a key role in team development, training, and process improvement. Responsibilities include reviewing complex claims, assisting with training, and contributing to special projects. You will support leadership with inventory management, process development, and auditing. This role requires strong analytical skills, collaboration, and a commitment to improving departmental workflows.

Requirements

• High School Diploma4 + 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 independentlyBasic 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

Responsibilities

• Support team discussions, aid in team claims issue resolution efficiently, and lead by example
• Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures
• Foster a collaborative team culture through open, honest communicationAssist with training new team members and support ongoing development through continuous education and skills training
• Support in helping develop team members to perform at their highest level by offering coaching and sharing expertise/best practicesReview claims queues and provide expertise to address nuances with appropriate parties
• Continually meet department metrics and quality set forth by leadership Provide ongoing feedback to improve departmental workflows and procedures
• Communicate complex claims issues clearly through documentation and direct communications
• Process complex claim scenarios 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
• Provide feedback to leadership on system enhancements or training gaps

Preferred Qualifications

• Medical Coding experience/certification
• Medical Billing experienceUnderstanding of provider data
• Previous start-up company experience
• Degree in Healthcare Administration or similar field
• Training and ability to create processes/procedure documentation is a plus
• 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
• Annual bonus program
• Stock options