Claim Examiner II

POSITION SUMMARY 

The Claims Examiner II is responsible for the accurate and timely adjudication of complex healthcare claims within a managed care environment, with a focus on Dual Eligible Special Needs Plans (DSNP) and Medicare lines of business. This role involves advanced application of benefit plans, policies, and regulatory guidelines to ensure proper claim processing, including new claims, reprocessed claims, overturned disputes, and appeals. The Claims Examiner II serves as a subject matter resource to team members, supports quality and compliance initiatives, and plays a key role in ensuring payment accuracy and enhancing member and provider satisfaction.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

Key Responsibilities

• Review, analyze, and process complex medical claims in accordance with Medicare and DSNP benefit structures, policies, and procedures. 
• Process Institutional and Professional Claims, ensuring accurate application of benefits, coding, and reimbursement methodologies.
• Accurately adjudicate new day claims, ensuring proper application of benefits, coding edits, and pricing methodologies. 
• Handle higher-complexity claims, including those requiring detailed research, manual pricing, or exception handling. 
• Evaluate and process claim disputes and reconsiderations, including those that result in overturn decisions requiring correction and re-adjudication. 
• Handle appeals-related claim adjustments, ensuring timely and accurate implementation of appeal outcomes. 
• Interpret provider contracts, fee schedules, and reimbursement methodologies to ensure correct payment. 
• Ensure compliance with CMS (Centers for Medicare & Medicaid Services), state regulations, and internal policies. 
• Identify, investigate, and resolve complex claim issues, system errors, and potential compliance risks; escalate as needed. 
• Serve as a resource for Claims Examiner I staff by providing guidance, answering questions, and assisting with issue resolution. 
• Participate in audits, quality reviews, and contribute to corrective action plans as needed. 
• Maintain higher productivity and quality standards, consistently meeting or exceeding turnaround time requirements. 
• Document claim processing activities clearly and accurately in system notes. 
• Collaborate with internal departments such as Provider Relations, Appeals & Grievances, and Configuration teams to resolve claim issues and improve processes.

QUALIFICATIONS AND EDUCATION

Required Qualifications 

• High school diploma or equivalent; associate or bachelor’s degree preferred.
• Minimum of 4–6 years of claims processing experience in a managed care or health insurance environment.
• Strong knowledge of Medicare and DSNP claims processing guidelines, including benefit application and coordination of benefits (COB).
• Experience handling claims reprocessing, disputes, and appeals (including overturned cases).
• Familiarity with CPT, HCPCS, and ICD-10 coding.
• Understanding of provider contracts and reimbursement methodologies.
• Strong analytical and problem-solving skills with high attention to detail.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficiency in claims processing systems and Microsoft Office applications. 

Preferred Qualifications 

• Knowledge of CMS regulations and audit requirements.
• Prior experience working with dual-eligible populations.
• Medicare, Part C claims processing experience. 

Core Competencies

• Accuracy and attention to detail
• Regulatory compliance awareness
• Critical thinking and decision-making
• Time management and productivity
• Communication and collaboration

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement:

 
I have read this job description and understand what is expected of me while I occupy this role.