Claims Examiner II

The Claims Examiner is responsible for administratively reviewing, analyzing, and adjudicating claims of varying complexity. This role focuses on non clinical decision making and ensures processing integrity by validating accuracy, completeness, eligibility, coverage, and benefit application across all claims systems. The Claims Examiner reviews supporting documentation, identifies discrepancies or potential fraud, resolves issues through coordination with internal and external stakeholders, and ensures all claim outcomes align with policy, regulatory requirements, and established procedures.

Responsibilities:

• Review and analyze claim submissions across all claims processing systems to ensure completeness, accuracy, eligibility, and appropriate documentation.
• Verify coverage, pricing, authorizations, coordination of benefits (COB), and member eligibility in alignment with policy and regulatory requirements.
• Apply policy provisions, benefit guidelines, and regulatory rules to accurately adjudicate all administrative claim types, including in and out of network claims.
• Identify and address discrepancies such as incorrect billing, duplicate claims, or potential fraud indicators, escalating issues as appropriate.
• Determine and apply accurate benefit payments in accordance with organizational standards and required regulatory timeframe.
• Communicate with providers, enrollees, and internal teams to obtain missing or clarifying information and support timely claim resolution.
• Investigate complex or questionable claims to validate documentation and ensure claim integrity.
• Maintain accurate claim documentation and ensure compliance with HIPAA, privacy requirements, and all applicable regulations.
• Meet established productivity and quality standards while contributing to process improvements and staying current with policy updates and regulatory changes.

• 3+ years of experience w/High School.
• 2+ years' experience in a similar role; Associate degree preferred. Required to successfully complete claim examiner training and examinations.
• Proficient in basic computer operations and Microsoft Office Suite programs (Excel, Outlook, Word, etc).
• Effective written, verbal, and interpersonal communication skills to document claim decisions and communicate with internal partners and external clients.
• Ability to review information, identify the appropriate resolution, and recommend actions that ensure accurate, consistent, and outcome aligned results.
• High attention to detail to identify errors, inconsistencies, or missing documentation in claims.
• Ability to adapt quickly in fast-paced or changing environment.
• Ability to work effectively both independently with minimal supervision and collaboratively as part of a team.
• Knowledge of Delta Dental systems/organization and knowledge of health care industry issues preferred.

• Competitive base and incentive pay
• 401(k) with robust matching and non-matching contributions
• Rich medical & pharmacy benefits
• 100% employer-paid dental and vision benefits
• Holistic wellbeing program with deep financial incentives
• Generous paid time off plus 12 paid holidays and your birthday off
• Culture of growth and learning: career development; tuition reimbursement; recognition program
• Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
• Social responsibility and volunteer opportunities
• Employee discount program