Claims Examiner: Adjudication & Complex Claims

Excellus BCBS; Town of Clinton (NY); On-site; USD 28,000 - 41,000; Full time

Job summary

Excellus BCBS is seeking a Claims Examiner to process and adjudicate a wide range of claims, following MTM, NCQA, and PIP requirements. Level I through IV responsibilities escalate with experience, including identifying trends and communicating risks to leadership.

All Levels require a high school diploma, with a NYS Independent Adjuster license preferred or required for higher levels. Strong attention to detail and the ability to multi-task across systems are essential.

Qualifications

• High School diploma or equivalent required.
• Customer service or claims processing experience preferred.
• Ability to navigate Windows and multiple programs simultaneously.
• Strong self-management and attention to detail.
• Multi-tasking to resolve moderately complex claims and simple adjustments.
• NYS Independent Adjuster License and renewals maintained (as applicable).

Responsibilities

• Handle front end transactions including member eligibility and claim processing.
• Adjudicate, adjust and research claims in line with policies and procedures.
• Identify trends and communicate risk to leadership.
• Collaborate with internal departments and external customers as needed.
• Provide guidance and assist junior staff as assigned.

Education

High School diploma or equivalent

NYS Independent Adjuster License

Customer service / claims processing experience

Multi-tasking / attention to detail

Problem solving / reasoning

Self-management / working with multiple programs

Job description

Excellus BCBS is seeking a Claims Examiner to process and adjudicate a wide range of claims, following MTM, NCQA, and PIP requirements. Level I through IV responsibilities escalate with experience, including identifying trends and communicating risks to leadership.

All Levels require a high school diploma, with a NYS Independent Adjuster license preferred or required for higher levels. Strong attention to detail and the ability to multi-task across systems are essential.