Medical Claims Examiner

Highly complex medical claim reviewAdvance claim adjudicationAdvance claim history analysisReview medical record documentation to determine coding coverageComplex appeals and reconsiderationsEscalated claim resolutionComplex provider and payer issuesComplex duplicate claim investigationsPayer Audit-related claim reviewsComplex void and replace processingAdvance reprocessing resolutionResearch of system and adjudication issuesReview of recurring claim-processing problemsIdentify opportunities for process improvementAssist with system and workflow validationProvide subject-matter expertise to Levels 1 and 2Provide guidance and mentoring to Claims team membersAssist with training and knowledge transferSupport development and refinement of claims proceduresServe as a senior escalation and subject -matter resource for complex claim issues