Claims Examiner II

MetroPlus; New York (NY); On-site; USD 50,000 - 70,000; Full time

Job summary

MetroPlus is seeking a detail-oriented candidate to manage healthcare claims processing in New York. The ideal applicant will have a bachelor's degree and at least three years of experience in a managed care or hospital setting.

Responsibilities include processing complex claims, auditing work for accuracy, and assisting with retraining sessions. Proficiency in medical terminology and Microsoft Office is essential.

Qualifications

• Minimum three years of experience in claims within managed care or hospital setting.
• Proficient in Microsoft Office applications.
• Strong organizational and time management skills.

Responsibilities

• Process claims exceeding age parameters.
• Audit claims examiner work for accuracy.
• Assist in retraining sessions as directed.

Skills

Data entry

Medical terminology

CPT knowledge

ICD-P knowledge

Revenue codes

Education

Bachelor's degree

Master's degree (preferred)

Tools

Microsoft Word

Microsoft Excel

Microsoft Access

Job description

Position Overview

The ideal candidate will have experience processing healthcare claims in a high-volume Claims Department. Must be computer literate and have ability to enter data into computer system with speed and accuracy. Must be able to demonstrate time management and strong organizational skills.

Scope of Role & Responsibilities

• Process all claims identified as exceeding claim age parameters established within the unit (28+ days)
• Process complex, difficult, and non-routine claims for multiple lines of business
• Audit work of assigned claims examiners to ensure accuracy.
• Identify policies of common errors requiring retaining sessions
• Assist with retraining sessions as directed.
• Participate in quality projects as required by management.

Required Education, Training & Professional Experience

• Bachelor’s degree is required; a Master’s degree is preferred, or an equivalent combination of education and relevant experience that demonstrates satisfactory equivalency.
• At least three (3) years’ experience of claims in a managed care or hospital setting is required.
• Strong data entry skills are essential.
• In-depth knowledge of adjustment processing, medical terminology, CPT, ICD‑P, and revenue codes is required.
• Proficiency in Microsoft Office applications, including Word, Excel, and Access, is required.
• Must be capable of performing all duties and responsibilities of Claims Examiners within the department.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication
• Must be able to communicate adequately both verbal & written
• Must have excellent interpersonal skills