Medical Claims Examiner

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

Job summary

Alivi TPA of Florida, LLC seeks a Senior Medical Claims Examiner to perform highly complex claim reviews and adjudication in a full-time on-site capacity at our Miami, FL location. You will mentor team members, resolve escalated issues, and drive improvements in claims processing workflows.

The role requires a High School diploma, 3+ years in healthcare claims, Medicare knowledge, and strong analytical and communication skills. Proficiency with Excel, PowerPoint, Word, and Outlook is essential.

Qualifications

• High School diploma or equivalent.
• 3 years’ work experience in claims operations environment in the healthcare insurance processing Medicare.
• 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.
• Proficient with Excel, PowerPoint, Word & Outlook.
• Knowledge of CPT Codes, ICD-10 Codes and Revenue Codes.

Responsibilities

• Highly complex medical claim review.
• Advance claim adjudication.
• Advance claim history analysis.
• Escalated claim resolution.
• Payer Audit-related claim reviews.
• Complex provider and payer issues.
• Mentoring to Claims team members.
• Assist with training and knowledge transfer.
• Support development and refinement of claims procedures.
• Serve as a senior escalation resource for complex claim issues.

Skills

Claims processing

Medicare knowledge

Analytical thinking

Excel

Communication skills

Team collaboration

Education

High school diploma

Tools

Excel

PowerPoint

Word

Outlook

Job description

• Location 5775 Waterford District Drive,450,Miami, FL, 33126,United States
• Base Pay $22.00 - $24.00 / Hour
• Job Category ClaimsExaminer, ClaimsDepartment, Hiring
• Employee Type Regular Full Time
• Required Degree High school
• Manage Others No

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.

Summary

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.