Medical Claims Examiner II

About Gravie

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.

Employment Type: Full Time

About the Role

As Gravie looks to continue its member-centric approach to healthcare, the Medical Claims Examiner II will support, review and adjudicate claims in our best in class claim system. The Senior Medical Claims Examiner will be a subject matter expert capable of thoroughly evaluating, researching, and analyzing claim submissions with a solid knowledge of national claims guidelines. In addition to personally reviewing complex claims, the Senior Medical Claims Examiner will play a key role in elevating the performance of the team, assisting in training, serving as a resource to other Examiners, and pitching in as needed with special projects. The Senior Medical Claims Examiner will also support leadership with inventory management, process development, auditing, and other tasks as assigned.

What You Will Do

• Support team discussions, aid in team claims issue resolution efficiently, and lead by example.
• Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures
• Foster a collaborative team culture through open, honest communication
• Assist with training new team members and support ongoing development through continuous education and skills training.
• Support in helping develop team members to perform at their highest level by offering coaching and sharing expertise/best practices
• Review claims queues and provide expertise to address nuances with appropriate parties.
• Continually meet department metrics and quality set forth by leadership
• Provide ongoing feedback to improve departmental workflows and procedures.
• Communicate complex claims issues clearly through documentation and direct communications
• Process complex claim scenarios in accordance with Summary Plan Descriptions (SPDs). Areas of expertise include, but are not limited to: Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing.
• Provide feedback to leadership on system enhancements or training gaps.

What You Bring

• High School Diploma
• 4 + 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 and work independently
• Basic proficiency using Windows based other computer applications
• Functional comfort with Zoom, Microsoft Teams, or Google Meets
• General knowledge of CMS claims submission regulations
• Demonstrated success getting results through collaboration
• Excellent facilitation and transferable knowledge skills communicating effectively on complex concepts

Extra Credit

• Medical Coding experience/certification
• Medical Billing experience
• Understanding of provider data
• Previous start-up company experience