Senior Medical Claims Examiner: Complex Claims Expert

Sigma Systems, Inc.; Irving (TX); On-site; USD 52,000 - 72,000; Full time

Job summary

Sigma Inc. in Irving, TX is seeking a Claims Examiner Senior to review, analyze, research, and resolve complex medical claims in accordance with processing guidelines and federal regulations.

This role collaborates with multiple departments to ensure validation and quality assurance of claims processing, supporting claim corrections, refunds, and audits while maintaining high standards of performance and professional communication.

Qualifications

• Associate's degree or equivalent job-related experience required.
• Minimum of 3 years' experience processing medical claims in the healthcare industry.
• Prior experience with managed care, Medicare, Medicare Advantage, Health Exchange, and TRICARE is highly desirable.

Responsibilities

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Analyze medical claim information and take appropriate action for payment resolution in accordance with policies and procedures, desktops, processing guidelines, and federal regulations.
• Process medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, Home Health, Durable Medical Equipment providers, laboratories, etc.
• Work claim projects resulting from overpayments or underpayments related to manual processing errors, benefit updates, and/or contract, fee schedule changes.
• Process provider refunds, reconsiderations, and direct member reimbursements.
• Process medical claim adjustments, recovery of claim overpayments, and execution of claim batch adjudication.
• Solve moderately complex claims and escalating issues to the Claims Team Lead, Supervisor or Manager.
• Assist with database improvements and testing for system upgrades, conversions, or implementation of new processes.
• Serves as a resource to assist with training new associates, retraining current associates on new/updated desktops/policies and reports staff progress, deficiencies, and training needs to management.
• Sets high standards of performance and promotes teamwork to achieve established team goals, while maintaining a positive, professional attitude.
• Contacting/responding to internal and external customers for resolution on claim issues.
• Assist claims leadership to identify claim trends, gaps in workflow and create/update desktops and policies and procedures.
• Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals.
• Must be able to organize and prioritize work to meet deadlines.
• Have good judgment, initiative, and problem-solving abilities.
• Attention to detail is critical to ensure timely and accurate processing of claims.
• Consistently meet established productivity and quality standards.
• Follow CHRISTUS Guidelines related to HIPAA to prevent unauthorized disclosure of PHI.
• Performs other duties as assigned by management to support claims functions.

Skills

Communication skills

Attention to detail

Organizational skills

MS Office proficiency

Data entry

Education

Associate's degree or equivalent

Tools

Microsoft Office

Excel

PowerPoint

Word

Outlook

Job description

Sigma Inc. in Irving, TX is seeking a Claims Examiner Senior to review, analyze, research, and resolve complex medical claims in accordance with processing guidelines and federal regulations.

This role collaborates with multiple departments to ensure validation and quality assurance of claims processing, supporting claim corrections, refunds, and audits while maintaining high standards of performance and professional communication.