Medical Claims Examiner

We are looking for a detail-focused Medical Claims Examiner to join an insurance organization in Greenville, South Carolina. This position is suited for someone with hands-on experience adjudicating medical claims and applying plan provisions, coding standards, and pricing rules with accuracy. The person in this role will help ensure claims are processed efficiently, in compliance with benefit plans, contractual arrangements, and regulatory requirements.

Responsibilities:
• Review and adjudicate medical, dental, vision, and flexible spending account claims from intake through final payment determination.
• Examine suspended or flagged claims to identify billing discrepancies, duplicate submissions, unbundled charges, or other questionable claim activity.
• Resolve system-related claim exceptions by making manual corrections before claims are finalized for payment.
• Apply member benefits, provider contract terms, fee schedules, and applicable regulations to calculate accurate reimbursement outcomes.
• Interpret coding and billing details, including diagnosis and procedure information, to support proper claim handling.
• Escalate complex claim issues or unclear situations to leadership when additional review or guidance is needed.
• Manage assigned exception reports and follow through on outstanding claim items in a timely manner.
• Meet established productivity, turnaround, and quality expectations while maintaining dependable attendance at the Greenville, South Carolina worksite.

Qualifications:

• At least 1 year of direct medical claims processing and adjudication experience with responsibility for final payment decisions.
• Practical knowledge of applying plan benefits, including deductibles, coinsurance, copays, and benefits coordination.
• Working familiarity with ICD-10 diagnosis coding, CPT/HCPCS procedure coding, revenue codes, bill types, and explanation of benefits review.
• Experience using provider networks, contract terms, or fee schedules to price and evaluate claims accurately.
• Background in a third-party administrator, self-funded, or medical insurance claims environment is strongly preferred.
• Ability to distinguish true claims adjudication work from customer service, enrollment, billing-only, intake, or audit-only functions.
• Strong written and verbal communication skills, along with proficiency in Microsoft Word, Excel, and Outlook.
• Proven ability to manage a high-volume workload while maintaining accuracy and adapting to changing priorities.

Compensation

$45,000.00-$52,000.00 Yearly

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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.

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