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 in Florida is seeking a Claims Examiner III to process electronic claims, ensure proper filing procedures, and apply guidelines, coding, and pre-coding requirements.

You will adjudicate complex claims, verify eligibility, apply medical necessity guidelines, and support accurate payments while staying current with CMS changes and HIPAA requirements. The role requires strong Microsoft Office skills and experience with claims systems.

Qualifications

• 6+ years of claims adjustment or processing experience.
• Knowledge in podiatry, orthopedic, dermatology and/or pain management preferred.
• HIPAA/compliance knowledge.
• Medical terminology including ICD-10 and CPT.
• Associates degree preferred.

Responsibilities

• Process submitted electronic claims following guidelines and coding rules.
• Analyze and adjudicate complex claims not auto adjudicated.
• Investigate and resolve problem claims to prevent recurrence.
• Apply CMS changes affecting claims processing.
• Perform pre-payment audits and ensure accurate payments.
• Maintain SOPs and update knowledge through training.
• Ensure HIPAA compliance and proper member/provider identification.

Skills

MS Office

System processing

Research skills

Education

Associate degree preferred

Job description

Provider Network Solutions LLC in Florida is seeking a Claims Examiner III to process electronic claims, ensure proper filing procedures, and apply guidelines, coding, and pre-coding requirements.

You will adjudicate complex claims, verify eligibility, apply medical necessity guidelines, and support accurate payments while staying current with CMS changes and HIPAA requirements. The role requires strong Microsoft Office skills and experience with claims systems.