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Sr Claims Examiner

Job Category: Member Service

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Location: Lake Mary, FL, United States

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Job Description


The Senior Claims Examiner is responsible for the investigation, determination and reporting of claims processing thru auditing of normal business processes as well as handling second level appeal requests. The incumbent will audit, conduct root cause analysis, handle processing of determinations, track and trend findings. The Senior Claims Examiner will also assist management with measures to ensure processing and payment accuracy; and will ensure adherence to departmental, corporate and governmental policies and regulations.

  • Reviewing and investigating claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst Policy and Procedure.
  • Subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
  • Identifying defects and improving departmental performance by supporting quality, operational efficiency and production goals.
  • Reporting and presenting preliminary findings based on trending and interpretation.
  • Trending and comparing analyses against departmental and corporate standards.
  • Assist with developing and participating in effective training and documentation.
  • Soliciting and coordinating required information between Management staff and team members to complete daily assignments.   
  • Examining and Processing of Claims.   
  • Working on multiple audits, appeals or other ad hoc projects.
  • Additional duties as assigned

Minimum Qualifications:

  • High School Diploma or GED from an accredited institution
  • Experience identifying root cause claims adjudication process failures and ability to quantify departmental impact.
  • Experience with the investigation, determination and reporting of claims processes.
  • Experience with Power MHS and MACESS or similar claims system
  • Experience working within Excel spreadsheets which includes formatting formulas and filtering results.  As the Senior Claims Examiner you will be work on multiple audit, appeals or other ad hoc projects.
  • Experience handling Personal Health Information (PHI) in a professional manner.

Preferred Qualifications:

  • Associate degree or higher.
  • Experience in an Auditing capacity where you have conducted root cause analysis.
  • Ability to work analytically and provide creative ideas for problem solving.
  • Excellent time management skills for fast paced environment
  • Ability and willingness to handle increasing workload and responsibility.
  • Willingness and ability to learn and evaluate new information, both technical and procedural.
  • Excellent written and oral communication and interpersonal skills with the ability to demonstrate professionalism, diplomacy.

Compliance & Regulatory Responsibilities: N/A

License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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