Experienced Managed Care Claims Examiner

Experienced Managed Care Claims Examiner - Remote

Job Type: Full-Time
Work Setup:
Fully Remote

Work Hours:

Pacific Time Zone

We are seeking an Experienced Managed Care Claims Examiner to join our growing healthcare operations team. This role is responsible for accurately reviewing, investigating, adjudicating, and resolving medical claims and provider dispute requests in accordance with payer guidelines, contractual agreements, regulatory requirements, and internal policies.

This is a fast-paced, production-driven role requiring strong analytical skills, attention to detail, and the ability to process a broad range of claim scenarios. Successful candidates must be comfortable navigating complex claims, applying multiple benefit and reimbursement rules, and managing a high-volume workload while maintaining quality and accuracy standards.

The ideal candidate is self-motivated, accountable, adaptable, and committed to continuous learning and professional growth.

• Review and adjudicate medical claims while ensuring accurate coding, data entry, and application of appropriate reimbursement methodologies.
• Process a broad range of claim types, including professional, institutional, adjusted, corrected, and other complex claim scenarios.
• Review and investigate provider dispute requests (PDRs), appeals, reconsiderations, and claim adjustments.
• Verify member eligibility, provider participation, benefit coverage, and supporting documentation to facilitate accurate claim processing.
• Research claim discrepancies and determine appropriate claim outcomes based on contractual agreements, benefits, policies, and regulatory requirements.
• Request additional information and collaborate with internal stakeholders to resolve claim-related issues.
• Process claims from initial review through final adjudication while maintaining thorough documentation of decisions and actions taken.
• Handle complex claims involving multiple services, providers, benefits, or reimbursement methodologies.
• Identify and ... unusual or high-risk claims requiring additional review.
• Maintain detailed and accurate records of claims processing activities.
• Consistently achieve established productivity, quality, and timeliness standards.
• Participate in training, calibration sessions, and ongoing professional development initiatives.

This position supports a complex managed care environment and requires examiners to process a variety of claim types rather than a single specialized inventory.

Successful candidates must be comfortable:

• Learning and applying multiple benefit structures, reimbursement methodologies, and claim processing rules.
• Managing a high-volume workload while balancing quality, accuracy, and productivity expectations.
• Working independently and making sound claim decisions with limited supervision.
• Receiving feedback and coaching in support of continuous improvement.
• Adapting to evolving business needs, procedures, and claim scenarios.

• Minimum 3 years of healthcare claims adjudication experience, preferably within a managed care, health plan, TPA, or payer environment.
• Experience processing medical claims from initial review through final adjudication.
• Strong understanding of healthcare claims processing and reimbursement principles.
• Demonstrated ability to research, analyze, and resolve claim discrepancies and exceptions.
• Strong attention to detail and sound decision‑making skills.
• Ability to manage workload effectively and meet productivity expectations.
• Effective written and verbal communication skills.
• Ability to work independently and collaboratively within a team environment.
• Basic to intermediate Microsoft Office skills.
• Ability to perform basic mathematical calculations…