Claims Examiner

Job Summary

Reviewing written dispute requests from providers regarding denied or incorrect payments, the temporary remote Claims Examiner will interpret contracts, adjust claims as necessary, and ensure compliance with guidelines while maintaining accurate documentation.

Key responsibilities

• Review and interpret provider and health plan contracts to determine accurate claims payments or denials
• Adjust claims and calculate interest or penalties as applicable, while identifying and addressing potential system issues
• Document disputes in the Provider Dispute Database and communicate outcomes to providers in accordance with departmental guidelines

Required qualifications

• Experience in claims processing and dispute resolution
• Knowledge of RBRVS and Medicare guidelines
• Ability to interpret complex contracts and regulations
• Familiarity with claims management systems and documentation practices
• Proven track record of meeting quality and quantity standards in a claims environment