[Hiring] Medical Claims Examiner II @Gravie

Role Description

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. They are a subject matter expert capable of thoroughly evaluating, researching, and analyzing claim submissions with a solid knowledge of national claims guidelines. In addition to owning a high-volume, high-complexity caseload, this role may serve as a go-to resource for other Examiners, contribute to training and special projects, and support leadership with inventory management, process development, and auditing.

• 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.
• 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
  • High Dollar Claims Processing
• Review claims queues and provide expertise to address nuances with appropriate parties.
• Serve as a go-to resource for other Examiners, answering questions and helping resolve claims issues as they arise.
• Continually meet department metrics and quality standards set forth by leadership.
• Communicate complex claims issues clearly through documentation and direct communication.
• Provide ongoing feedback to leadership on workflow gaps, process improvements, system enhancements, and training needs.
• Support leadership with special projects as assigned, including inventory management, process development, and auditing.

Qualifications

• 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
• Functional comfort with Zoom, Microsoft Teams, or Google Meets
• General knowledge of CMS claims submission regulations
• Strong collaboration and communication skills within a team setting

Requirements

• Medical Coding experience/certification
• Medical Billing experience
• Understanding of provider data
• Degree in Healthcare Administration or similar field
• Previous experience using Javelina processing system
• Experience with training and ability to create processes/procedure documentation
• Previous start-up company experience

Benefits

• Alternative medicine coverage
• Flexible PTO
• Up to 16 weeks paid parental leave
• Paid holidays
• 401k program
• Transportation perks
• Education reimbursement
• 2 days of paid paw-ternity leave