Senior Healthcare Claims Examiner: Complex Adjudication

Provider Network Solutions LLC; Miami (FL); On-site; USD 55,000 - 75,000; Full time

Job summary

Provider Network Solutions LLC seeks a Claims Examiner III to process electronic claims, verify filing procedures, and apply coding and guidelines to ensure compliant submissions. The role includes adjudicating complex claims, applying medical necessity guidelines, performing pre-payment audits, and staying updated on CMS changes and HIPAA compliance within a fast-paced environment.

Strong analytical skills, proficiency with Microsoft Office, and experience with systems processing are essential,

Qualifications

• 6+ years of Claims Adjustment or processing experience.
• Familiarity with HIPAA policies and compliance.
• Knowledge of ICD-10 and CPT coding.

Responsibilities

• Process submitted electronic claims and ensure proper filing procedures.
• Review and apply guidelines, coding and eligibility verification.
• Investigate and resolve problem claims to prevent recurrences.
• Adjudicate complex claims unable to auto adjudicate.
• Apply medical necessity guidelines and determine coverage.
• Perform pre-payment audits and ensure CMS changes are followed.
• Maintain SOPs and update departmental standards.

Skills

Microsoft Office

Systems processing

Research skills

Education

Associates degree preferred

Job description

Provider Network Solutions LLC seeks a Claims Examiner III to process electronic claims, verify filing procedures, and apply coding and guidelines to ensure compliant submissions. The role includes adjudicating complex claims, applying medical necessity guidelines, performing pre-payment audits, and staying updated on CMS changes and HIPAA compliance within a fast-paced environment.

Strong analytical skills, proficiency with Microsoft Office, and experience with systems processing are essential,