Claims Examiner II

SUMMARY: The Claims Examiner II is responsible for reviewing, analyzing, and processing complex and/or exception healthcare claims to ensure accuracy, compliance, and timely adjudication. This position verifies coverage, evaluates documentation, and applies appropriate coding standards while adhering to regulatory requirements and organizational policies.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

1. Review and process complex claims for accuracy, completeness, and compliance with department policies and procedures, plan provisions and regulatory guidelines.
2. Verify member eligibility, coverage limits, and benefit coordination.
3. Analyze medical/dental records and billing codes (ICD, CPT, HCPCS, CDT) for proper coding and documentation.
4. Review and analyze claims inquiries from participants and providers.
5. Process complex claim adjustments to issue additional payments or recover overpayments.
6. Coordinate and manage claims exceptions, including recoveries, coordination of benefits, workers’ compensation, and third-party liability.
7. Provide professional and effective communication with plan participants, attorneys, and employer representatives using multiple channels, including phone, email, mail, and in-person.
8. Achieve or surpass departmental production and quality standards on a weekly, monthly, quarterly, and annual basis. 
9. Actively participate in system testing when needed.
10. Maintain current department knowledge of plan documents, summaries of plan provisions and other plan materials. 
11. Identify and recommend process improvements for internal workflow, system processes and updates to benefit plans.
12. Perform other job-related duties/special projects as assigned.
13. Abide by organizational and HIPAA guidelines, privacy practices, and confidentiality.
14. Comply with the policies of the Trust Fund, as set forth in the Employee Handbook.
15. Adhere to the company’s attendance policy.

EDUCATION and/or EXPERIENCE: 

1. High School diploma or GED required. 
2. 3-4 years of experience as a Claims Examiner. 
3. Registered Dental Assistant (RDA) License preferred
4. Knowledge of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), Medical Terminology and/or Current Dental Terminology (CDT)
5. Knowledge with International Classification of Diseases (ICD) ICD-9/ ICD 10 codes and guidelines
6. Able to utilize MS Office (Excel, Word and Outlook). Intermediate proficiency required.

Salary : $32 - $34