Senior Medicare Advantage Claims Specialist

Verda Healthcare; Huntington Beach (CA); On-site; USD 39,000 - 44,000; Full time

Benefits offered by this job

401(k)

Paid time off (vacation, holiday, sick

Health insurance

Dental Insurance

Vision insurance

Life insurance

Job summary

Verda Healthcare, Inc. in Huntington Beach, CA is seeking a Senior Claims Examiner to review, analyze, and adjudicate complex professional, institutional, inpatient, outpatient, and Medicare Advantage claims in accordance with CMS regulations, provider contracts, and benefit plans.

This role serves as a subject‑matter expert in claims processing, payment integrity, and compliance activities, supporting departmental productivity, training, and occasional audits.

Qualifications

• Minimum 5 years of healthcare claims processing experience.
• Minimum 2 years of experience adjudicating Medicare Advantage claims preferred.
• Experience with professional, institutional, inpatient, outpatient, and delegated claims processing.
• Strong knowledge of CMS regulations, provider contracting, reimbursement methodologies, and claims operations.

Responsibilities

• Review and adjudicate complex medical claims in accordance with plan benefits, CMS guidelines, provider contracts, fee schedules, and reimbursement methodologies.
• Analyze claim documentation, medical records, authorizations, coordination of benefits, and eligibility information to determine appropriate claim disposition.
• Process adjustments, reopenings, corrected claims, appeals, and Provider Dispute Resolution (PDR) cases within regulatory turnaround times.
• Investigate payment discrepancies, duplicate payments, overpayments, underpayments, and reimbursement issues.
• Review provider contracts, fee schedules, DRG, APC, ASC, and other reimbursement methodologies to validate accurate payment.
• Maintain accuracy, production, quality, and timeliness standards established by the Claims Department.
• Document claim decisions, approvals, denials, adjustments, and overrides in the claims system.
• Research and respond to provider inquiries, claim escalations, and complex claim issues.
• Assist with audit requests, payment integrity reviews, compliance activities, and corrective action initiatives.
• Support training and mentoring of Claims Examiners and provide guidance on complex claims processing issues.
• Participate in special projects, system testing, implementation efforts, and operational improvement initiatives.

Skills

Claims adjudication

Analytical skills

Communication skills

Medicare claims

Medicaid claims

PDR and appeals

Education

High School Diploma or GED

Associate degree

Bachelor’s degree

Tools

Microsoft Excel

Outlook

Word

Claims management system

Job description

Verda Healthcare, Inc. in Huntington Beach, CA is seeking a Senior Claims Examiner to review, analyze, and adjudicate complex professional, institutional, inpatient, outpatient, and Medicare Advantage claims in accordance with CMS regulations, provider contracts, and benefit plans.

This role serves as a subject‑matter expert in claims processing, payment integrity, and compliance activities, supporting departmental productivity, training, and occasional audits.