Are you a meticulous professional with a deep understanding of healthcare systems and a passion for ensuring accuracy and compliance? Explore a career as a Senior Claims Examiner, a pivotal role within the insurance and healthcare administration sectors. Senior Claims Examiner jobs represent a critical step beyond entry-level processing, demanding advanced analytical skills, independent judgment, and a comprehensive grasp of complex medical billing and regulatory frameworks. Professionals in this senior capacity are entrusted with the final review and resolution of intricate, high-value, or problematic medical claims, serving as a key control point for financial accuracy and regulatory adherence. Typically, a Senior Claims Examiner is responsible for the end-to-end management of non-routine claims. This involves meticulously reviewing and analyzing medical claims submitted by providers (using forms like CMS-1500 or UB-04) for accuracy in coding, billing, and adherence to policy benefits and provider contracts. They research discrepancies, apply nuanced processing guidelines, and determine appropriate payment, denial, or adjustment actions. A core function is ensuring strict compliance with federal and state regulations, such as HIPAA, and staying current with evolving healthcare laws. Their work often includes processing claim adjustments, managing overpayment recoveries, and handling provider reconsiderations or member reimbursements. Beyond individual casework, Senior Claims Examiners frequently collaborate with other departments like Network Management, Appeals, and IT to resolve systemic issues, test system upgrades, and improve overall claims workflow efficiency. The role also carries a significant mentorship and quality assurance component. Senior examiners commonly serve as subject-matter experts and resources for junior team members, assisting with training, answering complex questions, and helping to maintain high team performance standards. They are expected to identify trends in claims errors, report on workflow gaps, and contribute to the development and updating of processing manuals and departmental policies. Success in these jobs requires consistently meeting productivity and quality benchmarks while handling a sensitive workload with utmost confidentiality. Typical requirements for Senior Claims Examiner jobs include several years of progressive experience in medical claims processing within a health plan, insurance company, or large healthcare provider setting. Expertise in medical terminology, CPT/HCPCS procedure codes, ICD-10 diagnosis codes, and standard reimbursement methodologies (like DRG, APC) is essential. Candidates must possess strong analytical and problem-solving abilities, exceptional attention to detail, and proficient computer skills, including mastery of claims processing software and Microsoft Office applications. Excellent written and verbal communication skills are crucial for interacting with providers, members, and internal stakeholders. While an associate degree in a related field is often preferred, equivalent job experience is highly valued. For those seeking a challenging role that blends deep technical knowledge with analytical thinking and leadership, Senior Claims Examiner jobs offer a stable and rewarding career path at the heart of healthcare operations.
