The Claims Examiner III will evaluate and process complex claims, support team operations, train other examiners, and enhance department workflows.
Hi, we’re Gravie. Our mission is to improve the way people purchase and access healthcare through innovative, consumer-centric health benefit solutions that people can actually use. Our industry-changing products and services are developed and delivered by a diverse group of unique people. We encourage you to be your authentic self - we like you that way.
A Little More About The role:
As Gravie looks to continue its Member-centric approach to healthcare, the Claims Examiner III will support, review and adjudicate claims in our best in class claim system. The Claims Examiner III will be a subject matter expert capable of thoroughly evaluating, researching, and analyzing claim submissions with a solid knowledge of national claims guidelines. In addition to personally reviewing complex claims, the Claims Examiner III will play a key role in elevating the performance of the team, assisting in training, serving as a resource to other Examiners, and pitching in as needed with special projects. The Claims Examiner III will also support leadership with inventory management, process development, auditing, and other tasks as assigned.
You will:
· Support team discussions and aid in team claims issue resolution
· Support Claims Operations in testing claim scenarios, system configuration and system upgrades
· Support team members in reaching their full potential by providing coaching, sharing expertise, best practices, offering constructive feedback for improvement, and celebrating accomplishments.
· Process claims within designated queues and adjudicate them in accordance with established claims policies and guidelines
· Act as a liaison between team members and upper management to relay feedback, updates, and concerns.
· Review pended claim queues and apply expertise to resolve issues by collaborating with members of Claims Operations
· Conduct periodic reviews of claims and audit processes to identify opportunities for improving departmental outcomes
· Continually meet Key Performance Indicators (KPI’s) and quality expectations laid out by the department
· Play a key role in the development of departmental workflows
· Facilitate department-specific training, new hire training and ongoing education to support team development and knowledge retention
· Collaborate with QA team to determine necessary updates to department procedures to improve overall Financial and Payment accuracy
· Foster a collaborative team environment by actively participating in team discussions, offering support to colleagues, and maintaining a positive and solution-oriented attitude.
· Demonstrate a thorough understanding of complex claim scenarios and the ability to produce clear, concise written documentation outlining claim processing procedures 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.
You bring:
· High School Diploma
· 6 + 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
· Basic proficiency using Windows based other computer applications
· Functional comfort with Zoom, Microsoft Teams, or Google Meets
· General knowledge of CMS claims submission regulations
· Demonstrated success getting results through collaboration
· Excellent facilitation and transferable knowledge skills communicating effectively on complex concepts
· Proven ability to develop and implement medical claims processes
· Experience in managing and assigning claims inventory
Extra credit:
· Medical Coding experience/ Certification
· Medical Billing experience
· Understanding of provider data
· Previous start-up company experience
· Degree in Healthcare Administration or similar field
· Previous experience using Javelina processing system
Gravie:
In order to transform health insurance and build a health plan everyone can love, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career growth, meaningful mission-driven work, and an above average total rewards package.
The salary range for this position is $52,907 - $88,179 annually. Numerous factors including, but not limited to, educations, skills, work experience, certifications, etc. will be considered when determining compensation.
Our unique benefits program is the gravy, i.e., the special sauce that sets our compensation package apart. In addition to standard health and wellness benefits, Gravie’s package includes alternative medicine coverage, flexible PTO, up to 16 weeks paid parental leave, paid holidays, a 401k program, cell phone reimbursement, transportation perks, education reimbursement, and 1 week of paid paw-ternity leave.
A Little More About Us:
· 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 customers like us. Our revenue churn is in the low single digits, in an industry where greater than 20% churn is common.
· 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. We may not be the right place for everybody, but if you get energized by doing work every day that focuses on putting consumers at the front of the line, we could be a great place for you. It takes unique people and diverse perspectives to deliver our results. We encourage you to be your authentic self – we like you that way.
Top Skills
Google Meets
Microsoft Teams
Windows Applications
Zoom
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