经验丰富的管理护理索赔审核员

Experienced Managed Care Claims Examiner - Remote
Job Type: Full-Time
Work Setup: Fully Remote
Work Hours: Pacific Time Zone
Position Overview
We are seeking an Experienced Managed Care Claims Examiner to join our growing healthcare operations team. This role is responsible for accurately reviewing, investigating, adjudicating, and resolving medical claims and provider dispute requests in accordance with payer guidelines, contractual agreements, regulatory requirements, and internal policies.
This is a fast-paced, production-driven role requiring strong analytical skills, attention to detail, and the ability to process a broad range of claim scenarios. Successful candidates must be comfortable navigating complex claims, applying multiple benefit and reimbursement rules, and managing a high-volume workload while maintaining quality and accuracy standards.
The ideal candidate is self-motivated, accountable, adaptable, and committed to continuous learning and professional growth.
Key Responsibilities

• Review and adjudicate medical claims while ensuring accurate coding, data entry, and application of appropriate reimbursement methodologies.

• Process a broad range of claim types, including professional, institutional, adjusted, corrected, and other complex claim scenarios.

• Review and investigate provider dispute requests (PDRs), appeals, reconsiderations, and claim adjustments.

• Verify member eligibility, provider participation, benefit coverage, and supporting documentation to facilitate accurate claim processing.

• Research claim discrepancies and determine appropriate claim outcomes based on contractual agreements, benefits, policies, and regulatory requirements.

• Request additional information and collaborate with internal stakeholders to resolve claim-related issues.

• Process claims from initial review through final adjudication while maintaining thorough documentation of decisions and actions taken.

• Handle complex claims involving multiple services, providers, benefits, or reimbursement methodologies.

• Identify and escalate unusual or high-risk claims requiring additional review.

• Maintain detailed and accurate records of claims processing activities.

• Consistently achieve established productivity, quality, and timeliness standards.

• Participate in training, calibration sessions, and ongoing professional development initiatives.

Role Expectations
This position supports a complex managed care environment and requires examiners to process a variety of claim types rather than a single specialized inventory.
Successful candidates must be comfortable:

• Learning and applying multiple benefit structures, reimbursement methodologies, and claim processing rules.

• Managing a high-volume workload while balancing quality, accuracy, and productivity expectations.

• Working independently and making sound claim decisions with limited supervision.

• Receiving feedback and coaching in support of continuous improvement.

• Adapting to evolving business needs, procedures, and claim scenarios.

Candidates seeking a highly specialized or narrowly focused claims role may find this position broader in scope than traditional claims processing positions.
Required Qualifications

• Minimum 3 years of healthcare claims adjudication experience, preferably within a managed care, health plan, TPA, or payer environment.

• Experience processing medical claims from initial review through final adjudication.

• Strong understanding of healthcare claims processing and reimbursement principles.

• Demonstrated ability to research, analyze, and resolve claim discrepancies and exceptions.

• Strong attention to detail and sound decision-making skills.

• Ability to manage workload effectively and meet productivity expectations.

• Effective written and verbal communication skills.

• Ability to work independently and collaboratively within a team environment.

• Basic to intermediate Microsoft Office skills.

• Ability to perform basic mathematical calculations and verify claim accuracy.

Preferred Qualifications

• Experience processing Provider Dispute Resolution (PDR), appeals, reconsiderations, and claim adjustments.

• Managed care or health plan claims processing experience.

• Experience processing multiple claim types and lines of business.

• Knowledge of medical terminology.

• Understanding of ICD-10, CPT, and HCPCS coding.

• Experience handling complex claims requiring research, interpretation, and independent judgment.

What Success Looks Like
Successful Claims Examiners consistently:

• Demonstrate accountability and ownership of their work.

• Maintain high levels of accuracy and productivity.

• Exercise strong critical-thinking and problem-solving skills.

• Adapt to new claim scenarios and changing business requirements.

• Work effectively with minimal supervision.

• Remain engaged, resilient, and solution-oriented when faced with complex workloads and challenging claim situations.

• Embrace continuous learning and professional development.

Ready to Grow Your Career?
We’d love to meet you! Click “Apply Now” and tell us why you’d be a great addition to the Imagenet team.
About Imagenet

Imagenet is a technology-forward healthcare operations partner with more than 25 years of experience helping healthcare payers manage critical administrative and operational processes. Founded in 2000 and headquartered in Tampa, Florida, Imagenet supports 150+ health plans through its payer clients.
Our teams help improve efficiency, accuracy, visibility, and service across complex healthcare operations, including digital mailroom, claims adjudication, contact center, member communications, and related administrative functions. By combining experienced operational teams, proven processes, and purpose-built workflow technology, Imagenet helps payers keep essential processes moving for the members, providers, and communities they serve.
Imagenet operates 10 secure facilities across the U.S. and one secure facility in Manila, Philippines.
Joining Imagenet means contributing to work that supports the healthcare operations members and providers rely on every day.
Originally posted on Himalayas