Claims Examiner III

Position Summary

The Claims Examiner III is responsible for processing submitted electronic claims to ensure proper filing procedures and that processing guidelines and rules have been followed. The Claims Examiner III also validates claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.

Duties and Responsibilities

Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.

Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.

Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.

Analyze and adjudicate complex claims that cannot be auto adjudicated.

Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containment measures.

Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter.

Follow any center for Medicare and Medicaid (CMS) changes affecting claims processing.

Perform pre-payment audit.

Follow company policies, procedures and guidelines to ensure legal compliance.

Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.

Update and maintain departmental and specialty network standards of operating procedure (SOP).

mplies with performance standards as set forth by the department head.


6+ years of Claims Adjustment experience/ previous claims processing experience.

Knowledge in Podiatry, Orthopedic, Dermatology and/or Pain Management specialties preferred.

Knowledge of HIPAA policies and Compliance.

Medical Terminology including ICD (10) and CPT Knowledge.

Associates degree preferred


Proficient in Microsoft Office programs.

Previous experience with systems processing.

Research skills


Data Entry and Documentation skills

Problem solving, Analytical and verbal communication skills

Ability to interpret medical documentation

Detailed oriented

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 7:00 a.m. to 6:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


This position requires less than 10% travel

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.