Medical Claims Examiner

Alivi; Miami (FL); On-site; USD 30,000 - 33,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401K with company match

Paid Holidays

Paid Time Off (PTO)

Short-Term Disability

Job summary

Alivi in Miami, FL seeks a Senior Medical Claims Examiner to act as a high-level, individual contributor and subject-matter resource for complex claims, escalations, appeals, and research-driven issue resolution.

Responsibilities include reviewing highly complex medical claims, advancing adjudication, and guiding Levels 1 and 2 peers. The role emphasizes mentoring, training, and process improvement within a healthcare claims team.

Qualifications

• High School diploma or equivalent.
• 3 years’ work experience in claims operations environment in the healthcare insurance processing Medicare (Preferred).
• Hands-on experience processing medical claims in insurance industry.
• Knowledge of Medicare Fee Schedule and alternative payment methods.

Responsibilities

• Highly complex medical claim review.
• Advance claim adjudication and history analysis.
• Handle complex appeals and reconsiderations.
• Escalated claim resolution and complex provider issues.
• Provide guidance and mentoring to Claims team members.
• Assist with training and knowledge transfer.
• Support development and refinement of claims procedures.
• Serve as senior escalation resource for complex claim issues.

Skills

Analytical thinking

Critical thinking

Communication skills

Teamwork

Multi-tasking

Problem-solving

Education

High School diploma

Tools

Excel

PowerPoint

Word

Outlook

Job description

The Senior Medical Claims Examiner is the highest individual contributor level within the Claims processing structure and serves as a subject-matter resource for complex claims, escalations, appeals/reconsideration and process-related issues requiring additional research, documentation review, or independent analysis.

Job Description

• Highly complex medical claim review
• Advance claim adjudication
• Advance claim history analysis
• Complex appeals and reconsiderations
• Escalated claim resolution
• Complex provider and payer issues
• Complex duplicate claim investigations
• Payer Audit-related claim reviews
• Complex void and replace processing
• Advance reprocessing resolution
• Research of system and adjudication issues
• Review of recurring claim-processing problems
• Identify opportunities for process improvement
• Assist with system and workflow validation
• Provide subject-matter expertise to Levels 1 and 2
• Provide guidance and mentoring to Claims team members
• Assist with training and knowledge transfer
• Support development and refinement of claims procedures
• Serve as a senior escalation and subject -matter resource for complex claim issues

Requirements

• High School diploma or equivalent.
• 3 years’ work experience in claims operations environment in the healthcare insurance processing Medicare. (Preferred)
• Hands-on working experience processing medical claims in insurance industry.
• Knowledge of Medicare Fee Schedule and alternative payment methods (global, cap, flat fees).
• Self-starter, ability to work independently and in a team environment.
• Strategic, analytical, process oriented and must have critical thinking skills.
• Excellent written and verbal communication skills.
• Ability to manage multiple priorities.
• Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities.
• Works well under pressure.
• Proficient with Excel, PowerPoint, Word & Outlook.
• Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10 Codes and Revenue Codes.
• Knowledge of Correct Coding (CCI) Edits.
• Experience in gathering all necessary documentation in preparation of Delegation Audits.
• Detailed knowledge of electronic billing processes universal billing forms.
• Knowledge of CMS/ACHA Regulations is desirable.
• Pervious Experience using Health Suite is desirable.
• Certified Professional Coder (CPC) is desirable.

Pay Range $22-$24

Benefit

Medical, Dental, Vision, 401K with company matching, STD, Paid Holiday, PTO