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Claims Examiner – Provider Dispute
Imagenet LLC. Investigate and resolve provider disputes related to denied, underpaid, or incorrectly processed claims .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in healthcare claims processing, including CPT, ICD-10, and HCPCS coding validation, while ensuring compliance with Medi-Cal and commercial insurance requirements. Proven ability to resolve provider disputes effectively and maintain high accuracy in claims adjudication.
Highest-signal resume keywords
Claims ProcessingProvider Dispute ResolutionCPT, ICD-10, HCPCS Coding ValidationMedicare Claims HandlingData Analysis and Visualization
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Claims AdjudicationCoding ValidationAuthorization VerificationEligibility VerificationClaims Denials and AdjustmentsData AnalysisHealthcare ComplianceMedical Necessity EvaluationClaims ReviewQuality Assurance
Soft Skills
CollaborationProblem-SolvingAttention to DetailCommunicationFlexibility
Tools & Technologies
EZCapIDXFacetsMicrosoft Office SuiteExcel
Industry Keywords
Medi-CalCommercial Insurance ClaimsHealthcare ClaimsThird-Party AdministratorHIPAAData Privacy RegulationsCybersecurity Standards
Tech Stack
Tools & technologiesCyber Security
About the role
Key responsibilities & impact- Investigate and resolve provider disputes related to denied, underpaid, or incorrectly processed claims
- Use EZCap to review claims history, adjudication data, and notes
- Interpret health plan policies, provider contracts, and regulatory requirements, especially Medi-Cal and commercial plans
- Review healthcare claims for accuracy and compliance across multiple specialties
- Evaluate authorization details and validate codes to ensure claim approval and compliance
- Detect discrepancies and determine appropriate claim denials or adjustments
- Collaborate with internal quality auditors to improve claims accuracy
- Process and review healthcare claims across Anesthesia, ARI, DME, Facility, MSK, Surgery, PAP Supplies, COB, and Lab
- Verify eligibility, coverage, CPT codes, and supporting documentation for Primary and Secondary Medicare claims
- Identify discrepancies and approve, deny, or adjust claims according to policy guidelines and medical necessity
- Maintain 98%+ accuracy in claims adjudication while meeting turnaround time and quality assurance standards
- Support provider satisfaction and compliance with dispute resolution timelines
Requirements
What you’ll need- High school diploma or equivalent; associate or bachelor’s degree is a plus
- At least 3–5 years of hands-on experience in provider dispute resolution within healthcare, third-party administrator (TPA), or health plan settings, including claims processing and adjudication
- Proficient in CPT, ICD-10, and HCPCS coding validation
- Experienced in handling Medicare claims and secondary coverage
- Skilled in claims denials, adjustments, and appeals processes
- Strong knowledge of authorization and eligibility verification
- Familiar with HIPAA, data privacy regulations, and basic cybersecurity standards
- Strong background in data analysis and visualization
- Experienced with claims adjudication platforms such as IDX and Facets
- Proficient in Microsoft Office Suite (Excel, Outlook, Word), with advanced Excel skills
- Can start ASAP
- Flexibility to transition to an office-based setup when necessary
- Ability to process claims across Anesthesia, ARI, DME, Facility, MSK, Surgery, PAP Supplies, COB, and Lab specialties
- Knowledge of Medi-Cal and Commercial Insurance Claims
- Knowledge of CPT codes, ICD-10, HCPCS, authorization details, eligibility, coverage, and medical necessity
Benefits
Comp & perks- HMO - Medical & Dental (coverage on Day1 plus 1 dependent)
- Transportation Allowance
- Internat Allowance
- Equipment will be provided
- Potential for remote work after successful completion of in-office training