Claims Examiner III

Description:

Verda Health Plan of Texas has a contract with the Center of Medicaid and Medicare Services (CMS) and a state license with the Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Claims Examiner III to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare health plan is looking for people like you who value excellence, integrity, care and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with Verda Healthcare, Inc. and we will support you all the way.

Position Overview
The Claims Examiner III performs advanced administrative, operational, and customer support duties that require independent initiative and sound judgment. This position is responsible for the analysis and adjudication of medical claims within a managed care environment. The role includes processing payment reconciliations and adjustments related to retroactive contract rates and fee schedule changes, as well as identifying root causes of claims payment errors and reporting them to management. The Claims Examiner III also manages provider inquiries and supports resolution efforts across departments.

This position reports to: Claims Operations Manager.

Responsibilities:

· Analyze and adjudicate complex medical claims in compliance with CMS guidelines and health plan policies.

· Review and apply appropriate fee schedules, contracts, and benefit plans.

· Perform claim payment reconciliations and retroactive adjustments.

· Identify patterns and root causes of payment discrepancies and escalate issues as needed.

· Respond to provider inquiries and coordinate with internal teams for resolution.

· Maintain documentation and track resolution outcomes.

· Ensure compliance with regulatory, contractual, and internal policies.

· Recommend process improvements based on claim trends and data analysis.

· Support training initiatives for new staff and peers as subject matter experts.

Requirements:

Minimum Qualifications

· High school diploma or GED required. Associate or bachelor’s degree preferred.

· Minimum of 3–5 years of experience in claims processing and adjudication, preferably within Medicare Advantage or managed care settings.

· Knowledge of CPT, HCPCS, ICD-10 coding, and CMS regulations.

· Strong analytical and problem-solving skills.

· Proficient in claims systems (e.g., Plexis, Facets) and Microsoft Office tools.

· Ability to handle confidential information in compliance with HIPAA.

Professional Competencies

· Strong attention to detail and accuracy

· Excellent verbal and written communication

· Customer service-oriented with a collaborative mindset

· Ability to work independently and prioritize tasks

· Commitment to continuous learning and quality improvement

Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type: Full-time

Benefits:

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance
• Dental Insurance
• Vision insurance
• Life insurance

Schedule:

• Full-time onsite (100% in-office)
• Hours of operations: 9am – 6pm
• Standard business hours Monday to Friday/weekends as needed
• Occasional travel may be required for meetings and training sessions.

Ability to commute/relocate:

• Reliably commute or planning to relocate before starting work (Required)

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

*Other duties may be assigned in support of departmental goals.