Under Senior Claims Examiner

Overview

The Senior Claims Examiner is responsible for reviewing, analyzing, and adjudicating complex and high-dollar medical claims across multiple product lines. This role requires expert-level interpretation of policy provisions, advanced understanding of medical coding, and thorough evaluation of medical records and provider documentation. The Senior Claims Examiner ensures accurate benefit determination, compliance with regulatory standards, and supports the Claims Department through collaboration, problem-solving, and mentorship of junior examiners.

• Complex Claims Review
  • Review, investigate, and adjudicate high-dollar, escalated, or complex individual health claims.
  • Interpret and apply policy contract language, endorsements, exclusions, and benefit limitations accurately.
  • Analyze medical records, billing statements, and supporting documentation to determine medical necessity and benefit eligibility.
• Technical Expertise
  • Apply advanced knowledge of ICD
    10, CPT, and HCPCS codes in determining proper claim outcomes.
  • Identify questionable coding or billing practices and escalate when appropriate.
  • Evaluate fraud indicators and refer cases to SIU or management as needed.
• Compliance & Quality Assurance
  • Ensure all claim determinations comply with state and federal regulations, including HIPAA and ACA requirements.
  • Maintain high standards of documentation accuracy for audit readiness.
  • Participate in quality reviews and contribute to continuous improvement efforts.
• Collaboration & Communication
  • Work closely with other Claims units, Underwriting, Customer Service, and other internal departments to resolve issues efficiently.
  • Communicate promptly and professionally with internal stakeholders regarding claim status, decisions, or exceptions.
  • Provide guidance to Claims Examiners regarding complex scenarios or policy interpretation.
• Team Support & Leadership
  • Support training and development of new or junior examiners.
  • Share expertise and contribute to cross training initiatives within the department.
  • Assist leadership with projects, reporting, or workflow improvements as requested.

Required:

• 57 years of claims experience, including complex or high-dollar medical claims (Individual insurance experience preferred).
• Strong knowledge of medical terminology, coding (ICD
  10, CPT, HCPCS), and healthcare billing practices.
• Ability to read, analyze, and interpret medical records.
• Excellent written and verbal communication skills.
• High attention to detail with strong analytical and organizational skills.
• Ability to work independently, meet deadlines, and manage competing priorities.
• Proficiency in claims management systems and Microsoft Office tools.
• Legally authorized to work in the United States.
• Ability to successfully pass a background check.

Preferred:

• Experience with Individual Indemnity products or supplemental health plans.
• Prior mentoring or team lead experience.
• Familiarity with state and federal regulatory requirements impacting health claims.

• High School diploma or equivalent (GED) required.

• Professional office environment with standard hours (Mon-Fri, 8am-5pm); occasional extended hours during peak times.
• Frequent use of computer, phone, and standard office equipment.
• Regular interaction with staff, leadership, and customers in a fast-paced, high-volume setting.
• Occasional standing, walking, and lifting of up to 15 pounds (e.g., supplies or equipment).
• Hybrid or remote work options may be available, depending on business needs and company policy.