Medical Claims Examiner

Description We are looking for a detail-oriented Medical Claims Examiner to join an insurance team in Greenville, South Carolina. This position is suited for someone with hands-on experience evaluating and adjudicating medical claims in a payer, third-party administrator, or self-funded benefits environment. The ideal candidate can interpret plan provisions, apply coding and pricing guidelines, and make accurate payment determinations while maintaining quality and productivity standards.

Responsibilities:

• Review medical, dental, vision, and flexible spending account claims from intake through final determination, ensuring each claim aligns with plan provisions and benefit rules.
• Examine pending claims for irregularities such as billing inconsistencies, duplicate submissions, unbundled services, or other questionable charge patterns, and resolve issues appropriately.
• Apply diagnosis, procedure, revenue, and bill-type information to support accurate claim evaluation, pricing, and adjudication.
• Calculate member and plan responsibility by assessing deductibles, copayments, coinsurance, coordination of benefits, and related payment factors.
• Process claims using provider contract terms, fee schedules, regulatory requirements, and internal claim handling standards.
• Correct system-related claim errors manually when needed before finalizing payment outcomes.
• Escalate unusual, high-risk, or complex claim situations to leadership for further review and direction.
• Complete assigned exception reporting and maintain established expectations for turnaround time, accuracy, and daily production.
• Work on site as required and contribute to consistent, dependable day-to-day claims operations. Requirements
• At least 1 year of direct medical claims processing and adjudication experience, including making final payment decisions rather than only supporting or reviewing claims.
• Demonstrated ability to process claims end to end, including benefit review, coding validation, pricing application, and adjudication.
• Working knowledge of medical coding and terminology, including ICD-10, CPT, HCPCS, revenue codes, and applicable bill types.
• Experience in a health insurance, third-party administrator, or self-funded claims environment is strongly preferred.
• Familiarity with explanation of benefits documents, coordination of benefits, and standard medical claims payment practices.
• Ability to manage high claim volumes while meeting quality, accuracy, and service expectations.
• Proficiency with Microsoft Office applications, including Word, Excel, and Outlook.
• Strong written and verbal communication skills, sound judgment, reliability, and the ability to adapt in a fast-paced setting.

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