Senior Medical Claims Examiner: Complex Adjudication

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

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.