Claims Examiner II

The Claims Examiner is responsible for administratively reviewing, analyzing, and adjudicating claims of varying complexity. This role focuses on non clinical decision making and ensures processing integrity by validating accuracy, completeness, eligibility, coverage, and benefit application across all claims systems. The Claims Examiner reviews supporting documentation, identifies discrepancies or potential fraud, resolves issues through coordination with internal and external stakeholders, and ensures all claim outcomes align with policy, regulatory requirements, and established procedures.

• Review and analyze claim submissions across all claims processing systems to ensure completeness, accuracy, eligibility, and appropriate documentation.
• Verify coverage, pricing, authorizations, coordination of benefits (COB), and member eligibility in alignment with policy and regulatory requirements.
• Apply policy provisions, benefit guidelines, and regulatory rules to accurately adjudicate all administrative claim types, including in and out of network claims.
• Identify and address discrepancies such as incorrect billing, duplicate claims, or potential fraud indicators, escalating issues as appropriate.
• Determine and apply accurate benefit payments in accordance with organizational standards and required regulatory timeframe.
• Communicate with providers, enrollees, and internal teams to obtain missing or clarifying information and support timely claim resolution.
• Investigate complex or questionable claims to validate documentation and ensure claim integrity.
• Maintain accurate claim documentation and ensure compliance with HIPAA, privacy requirements, and all applicable regulations.
• Meet established productivity and quality standards while contributing to process improvements and staying current with policy updates and regulatory changes.