Our client is seeking an experienced Medical Claims Examiner to support a healthcare claims review and audit project focused on commercial health plans. This fully remote contract opportunity will play a key role in evaluating claims accuracy, identifying compliance risks, and supporting audit-related initiatives. The ideal candidate will have strong claims analysis experience, knowledge of healthcare reimbursement practices, and familiarity with the No Surprises Act.
Key Responsibilities
- Review commercial medical claims to verify processing accuracy, payment integrity, and compliance with established policies and audit requirements.
- Analyze claims impacted by the No Surprises Act (NSA) , investigating supporting documentation and identifying discrepancies, exceptions, or areas requiring escalation.
- Conduct detailed claim reviews and maintain audit documentation to support findings, recommendations, and corrective actions.
- Collaborate with claims operations, compliance, and internal business partners to resolve claim-related issues and ensure adherence to regulatory guidelines.
- Evaluate denied, rejected, and adjusted claims to identify trends, root causes, and opportunities to strengthen processes and controls.
- Perform reviews across multiple plan structures and jurisdictions while ensuring consistent application of payer policies and coverage requirements.
- Utilize healthcare claims systems and reporting tools to document results, track audit activity, and support project deliverables.
Qualifications
- Previous experience working with healthcare or medical claims within a health plan, payer organization, TPA, or related environment.
- Experience conducting claims audits, investigations, quality reviews, or examiner-level claims analysis.
- Solid understanding of commercial insurance claims processing and medical billing practices.
- Knowledge of claim denials, rejected claims, payment adjustments, and common processing errors.
- Familiarity reviewing claims subject to varying state regulations and compliance requirements.
- Direct knowledge of the No Surprises Act (NSA) is required.
- Strong analytical and problem-solving skills with the ability to identify discrepancies, interpret claims data, and clearly document findings.
Claims Examiner in nashville metropolitan area at Unknown Company
This position is listed as contract and able to be worked remotely.