Medical Claims Examiner - Onsite

Our client has an exciting opportunity for a Claims Examiner to join their growing Claims Department. This is an onsite position based in Coral Gables, FL.

The Claims Examiner is responsible for the accurate and timely processing of healthcare claims, ensuring compliance with departmental procedures and industry standards. This role requires a deep understanding of hospital and physician billing, including Medicare, Medicaid, and Commercial claims processing. The ideal candidate will possess expertise in ICD-9 and ICD-10 coding, policy interpretation, and the use of CPT codes, hospital coding, and UB-04 forms. The Claims Examiner will be tasked with ensuring the quality and accuracy of processed claims, identifying cases for audit, and managing appeals and balance billing cases from start to resolution. The role also involves working with Medicare Advantage and capitation plans, contributing to risk assessment processes, and maintaining strong communication with clients and providers.

Duties & Responsibilities :

• Process and examine all incoming claims based on departmental procedures.
• Understand hospital and physician billing and collections, including Medicare A & B, Medicaid, Commercial and PPO claims processing.
• Interpret, apply, and comprehend policy terms, deductibles, coinsurance, copays and policy max
• Code ICD-9 and ICD-10 while utilizing expertise in claims processing, policy interpretation, CPT codes, hospital coding, UB-04 forms, and Correct Coding Initiative (CCI) principles.
• Meet clients' claims processing deadlines.
• Review and perform quality assessments of work being released to clients to ensure claims processing errors are kept at a minimum.
• Identify claims that should be audited by the Medical Team
• Follow up on network pending claims.
• Receive and register appeals / balance billing cases into the system and distribute according to department procedure.
• Review and determine, according to department procedure, how to resolve the appeal / balance billing.
• Provide continuous updates to both clients and providers until appeal / balance billing case is closed.
• Handle Provider Statements and invoices by contacting the providers to request a completed claim form.
• Work with Medicare Advantage plans, capitation plans, risk assessment process and payments.
• Performs other similar and related duties.

Required Experiences :

Required Skills :

The Client offers competitive pay and benefits, including :