Medical Claims Examiner

Robert Half • Greenville, SC • 3h ago

Description

We are looking for a detail-oriented Medical Claims Examiner to join an insurance team in Greenville, South Carolina. This position is suited for someone with hands-on experience evaluating and adjudicating medical claims in a payer, third-party administrator, or self-funded benefits environment. The ideal candidate can interpret plan provisions, apply coding and pricing guidelines, and make accurate payment determinations while maintaining quality and productivity standards.

Responsibilities:

Review medical, dental, vision, and flexible spending account claims from intake through final determination, ensuring each claim aligns with plan provisions and benefit rules.

Examine pending claims for irregularities such as billing inconsistencies, duplicate submissions, unbundled services, or other questionable charge patterns, and resolve issues appropriately.

Apply diagnosis, procedure, revenue, and bill-@type information to support accurate claim evaluation, pricing, and adjudication.

Calculate member and plan responsibility by assessing deductibles, copayments, coinsurance, coordination of benefits, and related payment factors.

Process claims using provider contract terms, fee schedules, regulatory requirements, and internal claim handling standards.

Correct system-related claim errors manually when needed before finalizing payment outcomes.

Escalate unusual, high-risk, or complex claim situations to leadership for further review and direction.

Complete assigned exception reporting and maintain established expectations for turnaround time, accuracy, and daily production.

Work on site as required and contribute to consistent, dependable day-to-day claims operations.

Requirements - At least 1 year of direct medical claims processing and adjudication experience, including making final payment decisions rather than only supporting or reviewing claims.

Demonstrated ability to process claims end to end, including benefit review, coding validation, pricing application, and adjudication.

Working knowledge of medical coding and terminology, including ICD-10, CPT, HCPCS, revenue codes, and applicable bill @types.

Experience in a health insurance, third-party administrator, or self-funded claims environment is strongly preferred.

Familiarity with explanation of benefits documents, coordination of benefits, and standard medical claims payment practices.

Ability to manage high claim volumes while meeting quality, accuracy, and service expectations.

Proficiency with Microsoft Office applications, including Word, Excel, and Outlook.

Strong written and verbal communication skills, sound judgment, reliability, and the ability to adapt in a fast-paced setting.

Robert Half is the world's first and largest specialized talent solutions firm that connects highly qualified job seekers to opportunities at great companies. We offer contract, temporary and permanent placement solutions for finance and accounting, technology, marketing and creative, legal, and administrative and customer support roles.

Robert Half works to put you in the best position to succeed. We provide access to top jobs, competitive compensation and benefits, and free online training. Stay on top of every opportunity - whenever you choose - even on the go. Download the Robert Half app (https://www.roberthalf.com/us/en/mobile-app) and get 1-tap apply, notifications of AI-matched jobs, and much more.

All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan. Visit roberthalf.gobenefits.net for more information.

© 2025 Robert Half. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking "Apply Now," you're agreeing to Robert Half's Terms of Use (https://www.roberthalf.com/us/en/terms) and Privacy Notice (https://www.roberthalf.com/us/en/privacy) .

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