Medical Claims Examiner II

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, and 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

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

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

We know healthcare. Our company was founded and is still led by industry veterans who have started and grown several market-leading companies in the space.

We have raised money from top tier investors who share the same long-term vision as we do of building an industry defining company that will endure over the long run. We are well capitalized.

Our clients love us. Customer satisfaction rates among employees using Gravie health plans consistently rank above 80% – nearly 40 points above the industry average.

Our culture is unique. We tend to be non-hierarchical, merit-driven, opinionated but kind people who thrive working in a high-performance, fast-paced environment. People at Gravie care deeply about making a positive impact in the lives of the people we serve.