Medical Claims Examiner II

Remote

Apply with AI Apply

Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

Candidates must possess a High School Diploma and at least 4 years of experience in processing, adjusting, or analyzing medical claims, preferably within a TPA environment. A strong understanding of CPT/HCPC and ICD-10 code rules is essential, along with the ability to prioritize, manage time effectively, and work independently. Basic proficiency in Windows-based applications and familiarity with video conferencing tools like Zoom, Microsoft Teams, or Google Meets are required. General knowledge of CMS claims submission regulations, demonstrated success in collaborative environments, and excellent communication skills for explaining complex concepts are also necessary. Medical coding/certification, medical billing experience, understanding of provider data, and previous start-up company experience are considered advantageous.

Responsibilities

The Medical Claims Examiner II will review, investigate, and verify coverage to ensure accurate processing of medical claims, adhering to Summary Plan Descriptions (SPDs), policies, and departmental procedures. This role involves supporting team discussions, resolving claims issues efficiently, and acting as a subject matter expert for complex claims, including Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing. The examiner will also assist in training new team members, provide coaching and share expertise, review claims queues, and communicate complex issues clearly. Additionally, they will provide feedback to leadership on system enhancements or training gaps, support leadership with inventory management, process development, and auditing, and continually meet department metrics and quality standards while contributing to workflow improvements.

Skills

Medical Claims

Claims Adjudication

Claims Processing

Healthcare

Training

Coaching

Process Development

Auditing

Inventory Management

Gravie

Health benefits and insurance solutions provider

About Gravie

Gravie provides health benefits by offering straightforward and affordable health plans, primarily targeting individuals and small to midsize businesses. Their main product, Comfort, stands out because it has no deductible and no copays for most common healthcare services, allowing members to access care without unexpected costs. Additionally, Comfort includes virtual care options for musculoskeletal and mental health issues. Gravie also offers a payment solution called Gravie Pay, which enables members to pay for healthcare expenses interest-free, further easing financial stress. Unlike traditional health plans, Gravie claims that Comfort members save on out-of-pocket costs, and employers switching to Gravie often see lower premium expenses. The company has a high retention rate, indicating that many employees choose to continue with the Comfort plan in subsequent years. Gravie's goal is to simplify health benefits and reduce the financial burden of healthcare for its members.

Minneapolis, MinnesotaHeadquarters

2013Year Founded

$333.3MTotal Funding

DEBTCompany Stage

Fintech, HealthcareIndustries

201-500Employees

Benefits

Health Insurance

401(k) Retirement Plan

401(k) Company Match

Paid Holidays

Paid Vacation

Paid Sick Leave

Flexible Work Hours

Paid Parental Leave

Wellness Program

Alternative Medicine Coverage

Cell Phone Reimbursement

Transportation Perks

Education Reimbursement

Paid Paw-ternity Leave

Risks

Potential backlash from traditional insurers could increase competition or lobbying.

Rapid ICHRA adoption may invite regulatory scrutiny or changes.

Aggressive expansion strategy could strain resources and lead to inefficiencies.

Differentiation

Gravie's Comfort plan offers zero deductibles and copays, unlike traditional health plans.

Gravie Pay provides interest-free payment solutions, reducing financial burdens for members.

Focus on virtual healthcare services enhances accessibility and member satisfaction.

Upsides

Increased ICHRA adoption since 2020 expands Gravie's market opportunities.

Comfort plan's zero-deductible model attracts cost-conscious employers and employees.

Virtual healthcare services align with rising demand, boosting member engagement.

Land your dream remote job 3x faster with AI

Try Jobo Free