Medical Claims Examiner II

Hi, we’re Gravie. Our mission is to create health benefits that actually benefit small and midsize businesses and their employees. Our innovative benefit solutions 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 this Role: As Gravie looks to continue its member-centric approach to healthcare, the Medical Claims Examiner II will support, review and adjudicate claims in our best in class claim system. They are a subject matter expert capable of thoroughly evaluating, researching, and analyzing claim submissions with a solid knowledge of national claims guidelines. In addition to owning a high-volume, high-complexity caseload, this role may serve as a go-to resource for other Examiners, contribute to training and special projects, and support leadership with inventory management, process development, and auditing. You will: - Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures - Process complex claim scenarios 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. - Review claims queues and provide expertise to address nuances with appropriate parties. - Serve as a go-to resource for other Examiners, answering questions and helping resolve claims issues as they arise - Continually meet department metrics and quality standards set forth by leadership - Communicate complex claims issues clearly through documentation and direct communication - Provide ongoing feedback to leadership on workflow gaps, process improvements, system enhancements, and training needs - Support leadership with special projects as assigned, including inventory management, process development, and auditing You bring: - High School Diploma - 4 + 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 - Functional comfort with Zoom, Microsoft Teams, or Google Meets - General knowledge of CMS claims submission regulations - Strong collaboration and communication skills within a team setting Extra credit: - Medical Coding experience/certification - Medical Billing experience - Understanding of provider data - Degree in Healthcare Administration or similar field - Previous experience using Javelina processing system - Experience with training and ability to create processes/procedure documentation - Previous start-up company experience 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 clients love us. Customer satisfaction rates among employees using Gravie health plans consistently rank above 80% – nearly 40 points above the industry average. - 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. BENEFITS 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, transportation perks, education reimbursement, and 2 days of paid paw-ternity leave.