Claims Examiner III

Employment Type: Full Time

Position Overview

Gravie is seeking a Claims Examiner III to support our member-centric approach to healthcare. This role involves reviewing and adjudicating claims within our claims system. The Claims Examiner III will be a subject matter expert with a deep understanding of national claims guidelines, responsible for evaluating, researching, and analyzing claim submissions. In addition to handling complex claims, this position will contribute to team performance through training, mentorship, and special projects. The role also supports leadership in inventory management, process development, and auditing.

Responsibilities

• Support team discussions and aid in resolving claims issues.
• Assist Claims Operations with testing claim scenarios, system configuration, and system upgrades.
• Provide coaching, share expertise, and offer constructive feedback to team members to foster their growth.
• Process and adjudicate claims within designated queues according to established policies and guidelines.
• Act as a liaison between team members and upper management for feedback and updates.
• Review pended claim queues and collaborate with Claims Operations to resolve issues.
• Conduct periodic reviews and audits of claims processes to identify improvement opportunities.
• Consistently meet Key Performance Indicators (KPIs) and quality expectations.
• Play a key role in the development of departmental workflows.
• Facilitate department-specific training, new hire training, and ongoing education.
• Collaborate with the QA team to update department procedures for improved financial and payment accuracy.
• Foster a collaborative team environment through active participation and support.
• Demonstrate thorough understanding of complex claim scenarios, including Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing.
• Produce clear, concise written documentation outlining claim processing procedures in accordance with Summary Plan Descriptions (SPDs).

Requirements

• High School Diploma.
• 6+ years of experience processing/adjusting and/or analyzing medical claims, preferably in a TPA environment.
• Strong knowledge of CPT/HCPC and ICD-10 code rules.
• Ability to set priorities, manage time effectively, and work independently.

Company Information

Hi, we’re Gravie. Our mission is to improve the way people purchase and access healthcare through innovative, consumer-centric health benefit solutions that people can actually use. Our industry-changing products and services are developed and delivered by a diverse group of unique people. We encourage you to be your authentic self - we like you that way.