Senior Claims Examiner

📋 Description

• Examine claim records to resolve first-level disputes and issue letters.
• Review and process second-level claims, including adjustments and corrected claims.
• Collaborate with leadership on trends in improper processing and dispute-related discrepancies.
• Assist the team in departmental duties and support short- and long-term goals.
• Establish and maintain effective relationships with team and interdepartmental staff.
• Coordinate with leadership on identified trends and claim-related concerns.

🎯 Requirements

• 3+ years health plan claims processing; 2+ years in claims disputes.
• Experience in MCP or PACE claims processing preferred.
• Experience with Medicare and Medicaid claims processing.
• Strong computer skills; MS Office (Excel/Outlook/PowerPoint/Word/Teams) and related systems.
• Ability to balance priorities, exercise discretion and resolve ambiguities.
• Proficient in managed health care and medical terminology (CPT/HCPCS/ICD-10).
• Understanding of Medicare/Medi-Cal pricing and DRG.

🎁 Benefits

• Medical insurance coverage (Medical, Dental, Vision).
• Work/life balance – 17 days of PTO, 12 holidays, and 6 sick days.
• Advancement opportunities — promotion from within.
• And additional benefits.