Medical Claims Examiner III

The Medical Claims Examiner III will adjudicate medical claims within a state-of-the-art claims system, applying national claims guidelines and established policies. This subject matter expert will evaluate, research, and analyze complex claim submissions, including Coordination of Benefits, Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements, Transplant Claims, and High Dollar Claims Processing. Responsibilities include supporting team discussions, resolving claims issues, assisting with system testing and upgrades, and providing coaching and feedback to team members. The role also involves managing pended claims, conducting audits to identify improvement opportunities, meeting Key Performance Indicators, developing departmental workflows, facilitating training, and collaborating with the QA team on procedure updates. Additionally, the examiner will act as a liaison between team members and upper management, relaying feedback and concerns, and documenting claim processing procedures clearly and concisely.