Medical Claims Examiner II

Hi, we’re Gravie. Our mission is to improve the way people purchase and access healthcare through innovative, consumer-centric health benefit solutions that people can actually use. Our industry-changing products and services are developed and delivered by a diverse group of unique people. We encourage you to be your authentic self - we like you that way.

A Little More About this Role: As Gravie looks to continue its member-centric approach to healthcare, the Medical Claims Examiner  II will support, review and adjudicate claims in our best in class claim system. The Senior Medical Claims Examiner will be a subject matter expert capable of thoroughly evaluating, researching, and analyzing claim submissions with a solid knowledge of national claims guidelines. In addition to personally reviewing complex claims, the Senior Medical Claims Examiner will play a key role in elevating the performance of the team, assisting in training, serving as a resource to other Examiners, and pitching in as needed with special projects. The Senior Medical Claims Examiner will also support leadership with inventory management, process development, auditing, and other tasks as assigned.

- Support team discussions, aid in team claims issue resolution efficiently, and lead by example.

- Accurately review, investigate, and verify coverage to ensure proper processing of medical claims, identifying key processing requirements based on Summary Plan Descriptions (SPD), policies, and departmental procedures

- Foster a collaborative team culture through open, honest communication

- Assist with training new team members and support ongoing development through continuous education and skills training.

- Support in helping develop team members to perform at their highest level by offering coaching and sharing expertise/best practices

- Review claims queues and provide expertise to address nuances with appropriate parties.

- Continually meet department metrics and quality set forth by leadership Provide ongoing feedback to improve departmental workflows and procedures.

- Communicate complex claims issues clearly through documentation and direct communications

- Process complex claim scenarios in accordance with Summary Plan Descriptions (SPDs). Areas of expertise include, but are not limited to: Coordination of Benefits (COB), Prior Authorization, Claim Adjustments, Health Reimbursement Arrangements (HRA), Transplant Claims, and High Dollar Claims Processing.

- Provide feedback to leadership on system enhancements or training gaps.

- High School Diploma4 + years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment Strong knowledge of CPT/HCPC and ICD-10 code rules

-Ability to set priorities, manage time and work independently

-Basic proficiency using Windows based other computer applications

-Functional comfort with Zoom, Microsoft Teams, or Google Meets General knowledge of CMS claims submission regulations

-Demonstrated success getting results through collaboration

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Excellent facilitation and transferable knowledge skills communicating effectively on complex concepts

- Medical Coding experience/certification

-Medical Billing experience Understanding of provider data

-Previous start-up company experience

-Degree in Healthcare Administration or similar field

-Training and ability to create processes/procedure documentation is a plus

- Previous experience using Javelina processing system

In order to transform health insurance and build a health plan everyone can love, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career growth, meaningful mission-driven work, and an above average total rewards package.

The salary range for this position is $43,725 - $72,875 annually. Numerous factors including, but not limited to, education, skills, work experience, certifications, etc. will be considered when determining compensation. In addition to base salary, this position is also eligible to participate in Gravie’s annual bonus program. Stock options may also be awarded as part of the compensation package.

Our unique benefits program is the gravy, i.e., the special sauce that sets our compensation package apart. In addition to standard health and wellness benefits, Gravie’s package includes alternative medicine coverage, flexible PTO, up to 16 weeks paid parental leave, paid holidays, a 401k program, cell phone reimbursement, transportation perks, education reimbursement, and 1 week of paid paw-ternity leave. 

We know healthcare. Our company was founded and is still led by industry veterans who have started and grown several market-leading companies in the space. We have raised money from top tier investors who share the same long-term vision as we do of building an industry defining company that will endure over the long run. We are well capitalized. Our customers like us. Our revenue churn is in the low single digits, in an industry where greater than 20% churn is common. Our culture is unique. We tend to be non-hierarchical, merit-driven, opinionated but kind people who thrive working in a high-performance, fast-paced environment. People at Gravie care deeply about making a positive impact in the lives of the people we serve. We may not be the right place for everybody, but if you get energized by doing work every day that focuses on putting consumers at the front of the line, we could be a great place for you. It takes unique people and diverse perspectives to deliver our results. We encourage you to be your authentic self – we like you that way.