Claims Examiner

  • Location
    Farmington Hills, Michigan
  • Category
  • Job reference:
  • Job Type

  1. Summary:

Position is primarily responsible for answering escalated claim adjustment requests and resolving issues received through transferred provider phone calls, customer service management and miscellaneous special project work.


  1. Essential functions
  • Answers CNSHC claim inquiries via live transfer and resolves issues real time
  • Thoroughly researches post payment claims and takes appropriate action to resolve them within turnaround time requirements and quality standards
  • Acts as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature relating to claims.
  • Processes claim adjustment and provide appropriate level of coaching, analysis and resolution to Customer Care Representative.
  • Identify root cause issues related to billing and communicate findings as needed.
  • Evaluate and report financial payment accuracy on claims processors.
  • Process reports to improve informational resources.
  • Process claims in accordance with the plan benefits, authorization requirements, coordination of benefits, subrogation, and state insurance mandates.
  • Maintain a quality level of 96% or better.
  • Handle investigation and data input of coordination of benefits and subrogation information.
  • Assist with special projects related to department process improvements, fraud, waste and abuse identification or other issues.
  • Assist in education of Providers as it relates to claims processing.
  • Log, track and document all issues utilizing online systems and procedures, and in accordance with all applicable guidelines and requirement while on call with Providers.
  • Utilize Customer services skills to create a high-quality customer experience, as reflected through Provider feedback, quality monitors and payment accuracy.
  • Resolve critical errors as it relates to rejections, coding denials, claims processing and pricing.
  • Assists with other duties or special projects as assigned or directed


  1. Competency
    • Knowledge of ICD-10 codes
  2. Supervisory responsibilities—None
  3. Work environment—Office Setting
  4. Physical demands—the physical demands of the job, including bending, sitting, lifting and driving.
  5. Position type and expected hours of work—full time
  6. Travel—10% minimal
  7. Required education and experience
    • High School Diploma
    • Medical coding or billing certification
    • 1 year of experience in previous claims or health insurance
    • 9 months to 1year experience
  8. Preferred education and experience—None
  9. Additional eligibility qualifications—None

Please apply with your CV to:

An Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

EEO - EEO Poster Suppl - Affimative Action Policy
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