The potential pay range for this role is $22 - $24 per hour.

This is a hybrid position open to candidates within a 40-mile radius of our headquarters in Miami. For those residing more than 40 miles away, the role will be fully work-from-home. 

SUMMARY
The Medical Claims Examiner will ensure all claims received conform with all health plan, regulatory, contractual, compliance, and Alivi billing guidelines and processes. This role involves verifying the accuracy and completeness of claims, ensuring compliance with network provisions and state and federal regulations, and coordinating with healthcare providers to resolve discrepancies. Proficiency in medical terminology and healthcare billing practices is essential. Familiarity with data analysis will also ease the ability to communicate effectively with various stakeholders. The goal is to ensure timely and accurate reimbursement for covered medical services.

DUTIES & RESPONSIBILITIES
• Responsible for accurate and timely adjudication of professional and institutional claims according to state and federal regulations.
• Analyzes, processes, researches, adjusts, and adjudicates claims with the use of accurate procedure/revenue and ICD-10 Codes, according to provider contract and member benefits.
• Research and respond to provider disputes to ensure appropriate resolution in a timely manner.
• Refers disputes related to the level of service and/or medical necessity to designated clinical review resource and Network Operations Team and responds to the provider based on clinical feedback.
• Generates written correspondence to providers.
• Responds and assists other departments with complex issues for resolution or affirmation of previously processed claims and existing guidelines.
• Determines and processes overpayments (provider refunds) and reimbursement requests according to specific state and/or federal guidelines or as agreed to in provider contract.
• Determines and processes underpayments (internal errors) and provider reimbursement requests, which may involve the use of spreadsheet research and correspondence.
• Maintains the department’s claim edit rules and processing claims according to client specific verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing.
• Identifies trends in claims flows and suggests process improvements.
• Assist in preparation with Claims Audits.
• This position description identifies the responsibilities and tasks typically associated with the performance of the position.

REQUIREMENTS
• College education in health services administration, accounting, business, or similar discipline or equivalent experience.
• Certified Coding Specialist (CCS)/Certified Coder Associate (CCA)/AAPC - CPC Certified Professional Coder desirable.
• 3 years of work experience in claim operations in healthcare.
• Knowledge of Medicare/Medicaid fee schedules and alternative payment methodologies (global, cap, flat fees, etc.).
• Demonstrate skills in problem-solving, benefit plan, and provider contract Interpretation.
• Self-starter, ability to work independently and in a team environment.
• Strategic, analytical, process-oriented, and must have critical thinking skills.
• Ability to manage multiple priorities.
• Excellent follow-up abilities, willingness to be flexible, and adaptable to changing priorities.
• Proficient with Excel, PowerPoint, Word & Outlook.
• Knowledge of Correct Coding (CCI) Edits and CMS guidelines is required.
• Knowledge of CMS/ACHA Regulations is desirable.