Claims Examiner Senior \ 160

Claims Examiner Senior Irving

TX 75039

- Onsite

Shift:

8 AM - 5 PM Monday-Friday

Duration:

13+ Weeks

Notes:

Proof of education; High School Diploma Minimum of 3 years' experience processing medical claims in the healthcare industry. The Claims Examiner Senior is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines and desktops, as well as, ensuring compliance with federal regulations. This role works in conjunction with Business Configuration, Network Management, Provider Data, Complaints, Appeals and Grievances as well as other operational departments to ensure validation and quality assurance of claims processing.

Responsibilities:

Meets expectations of the applicable

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 escalate 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 #TB_PH #ZRHC Why TalentBurst? At TalentBurst, we deliver more than talent, we deliver outcomes. We partner with you to move quickly and connect you to opportunities aligned with your skills and long term growth. Backed by precision, transparency, and results, we connect top talent with leading organizations through trusted partnerships. We offer competitive compensation and comprehensive benefits, including medical, dental, vision, and retirement options. TalentBurst is an equal opportunity employer committed to an inclusive and diverse workforce.