[Hiring] Medicare Claims Examiner @TEKsystems

Role Description

Seeking an experienced Medicare Claims Examiner to join their team in a fully remote position. This is an excellent opportunity for candidates with a strong background in Medicare claims processing, D-SNP plans, and health plan operations.

Important: Candidates must reside in California and have hands-on QNXT experience. QNXT is a required qualification and candidates without QNXT experience will not be considered.

Responsibilities

• Review, research, price, and process paper and electronic claims
• Research and resolve pended and denied D-SNP claims
• Determine claim payment eligibility and accurately adjudicate claims
• Review manual review and audit reports
• Maintain documentation related to CPT, HCPCS, ICD, and HCFA coding
• Ensure compliance with Medicare, Medi-Cal, CMS, and health plan guidelines
• Communicate with internal departments regarding claim issues and resolutions
• Identify trends and support process improvement efforts
• Meet productivity, quality, and turnaround-time expectations

Qualifications

• 3+ years of Claims Examiner or healthcare claims processing experience
• Medicare and/or Medi-Cal claims processing experience
• D-SNP (Dual Eligible Special Needs Plan) experience
• Health plan experience
• Strong understanding of claims adjudication and payment determination
• Experience working in a high-volume production environment
• Knowledge of CPT, HCPCS, ICD, and HCFA coding
• Medical terminology knowledge
• Strong analytical, organizational, and communication skills
• Ability to work independently in a remote environment
• Proficiency with Microsoft Office and claims processing systems

Requirements

• QNXT experience is required
• Medicare Advantage and/or D-SNP experience is required
• Health plan experience is required
• Must currently reside in California
• Must be comfortable working in a production-driven environment

Benefits

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)