We are seeking a detail-oriented Medical Claims Examiner to join our team. In this role, you will review, analyze, and process medical claims accurately and efficiently while ensuring compliance with company policies, client requirements, and regulatory guidelines. The ideal candidate will have strong knowledge of claims adjudication, medical terminology, and healthcare insurance processes. Experience with EZ-CAP is a plus, and grievances experience is highly preferred.

Key Responsibilities:

Review and process medical claims for accuracy, completeness, and eligibilityAnalyze claims to determine coverage, payment, and denial outcomesResearch and resolve claim discrepancies, adjustments, and pended claimsInterpret provider contracts, benefit plans, and reimbursement guidelinesEnsure timely adjudication of claims in accordance with turnaround standardsInvestigate and respond to inquiries related to claims status, denials, and escalationsMaintain accurate documentation of claim actions and decisionsCollaborate with internal departments, providers, and health plan representatives to resolve complex claims issuesAssist with appeals and grievance-related cases as neededStay current on policies, procedures, and regulatory requirements affecting claims processing