Claim Examiner I

*POSITION SUMMARY * The Claims Examiner I is responsible for the accurate and timely adjudication of healthcare claims within a managed care environment, with a focus on Dual Eligible Special Needs Plans (DSNP) and Medicare lines of business. This role involves applying benefit plans, policies, and regulatory guidelines to ensure proper claim processing, including new claims, reprocessed claims, overturned disputes, and appeals. The Claims Examiner plays a critical role in maintaining compliance, ensuring payment accuracy, and supporting members and Provider satisfaction. *ESSENTIAL DUTIES AND RESPONSIBILITIES* To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to: *Key Responsibilities* * Review, analyze, and process medical claims in accordance with Medicare and DSNP benefit structures, policies, and procedures. * Accurately adjudicate *new day claims*, ensuring proper appli