As a Member Claims Examiner, you'll play a critical role in reviewing and resolving complex medical claims issues, leveraging your expertise in medical plan operations to drive accurate and timely claim adjudication. With a focus on delivering exceptional member experiences, you'll utilize your in-depth knowledge of regulatory requirements, network partner relationships, and medical coding to expertly investigate and resolve intricate member issues, ensuring seamless integration of claims processing and member services.

We're seeking an experienced professional to join our team, bringing advanced analytical and problem-solving skills to review and resolve complex medical insurance claims. You'll work closely with our teams to ensure seamless integration of claims processing, member services, and regulatory compliance, driving exceptional results and member satisfaction.

What you'll do:

• Review and adjudicate complex medical insurance claims, applying industry expertise and knowledge of regulatory requirements
• Conduct in-depth investigations and analysis to resolve member issues, ensuring timely and accurate resolutions
• Maintain expertise in medical plan operations, including claims processing, network partner relationships, and medical coding
• Collaborate with cross-functional teams to identify and implement process improvements, enhancing efficiency and member experience
• Provide expert guidance and support to junior team members, sharing knowledge and best practices

To be successful in this role, you'll need:

• 3+ years of experience reviewing and adjudicating medical insurance claims in a Third-Party Administrator (TPA) or health insurance setting
• Proven analytical and problem-solving skills, with ability to navigate complex claims issues
• Strong knowledge of medical plan operations, including claims processing, regulatory requirements, and medical coding
• Familiarity with medical terminology, anatomy, and physiology to accurately interpret medical records and claims data.
• Excellent communication and interpersonal skills, with ability to collaborate with diverse stakeholders
• Ability to work in a fast-paced environment, prioritizing multiple tasks and deadlines

Nice To Have:

• Bachelor's degree or 5+ years of health insurance customer servicing experience
• Experience interpreting and applying plan documents, including Summary Plan Descriptions (SPDs) and other relevant plan documents, to determine claim payment and benefits
• Previous experience working with and following regulatory requirements, such as HIPAA, ACA, or other healthcare-related laws and regulations
• Possess industry-recognized certifications, such as CPC (Certified Professional Coder) or CCS (Certified Coding Specialist).
• Familiarity with the 837 EDI format, with the ability to read, interpret, and apply claims data to resolve complex claims issues.

Pay Transparency Statement

This is a hybrid position based out of our Plano office, with the expectation of being in office at least three weekdays per week. #LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the hourly rate, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.