Claims Examiner III at Bright Health | Powderkeg

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Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.

What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.

If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.

General Purpose

Processes and Adjudicates Facility UB04 and Professional CMS 1500 claims by all claims policies, and contracts, keeping in compliance with industry regulations and guidelines.

Duties and Responsibilities

  • Meets or exceeds claims standard of 95% or greater in the accuracy of claims processing, along with meeting or exceeding overpayment and underpayment standard of 98% or greater.
  • Meet or exceed the department standard of the production quota set by the type of claim.
  • Apply all claims policies, contracts, and practices, and keep in compliance with industry regulations and guidelines.
  • Must be able to work and make claims resolution with limited supervision.
  • Confirm eligibility for claim billed and date of service.
  • Match and link authorization for required claims.
  • Comply with claims timeliness guidelines: Medicare non-contracted claims 30 calendar days; Medicare contracted claims 60 calendar days.
  • Proficient in, and performs the application of “Coordination of Benefits”.
  • Proficient in, and knows how to use and apply Health Plan Benefit Matrices and Division of Financial Responsibility.
  • Complies with all Company and Department Policies and Procedures.
  • Proficient with Federal and State requirements in claims processing.
  • Proficient understanding of the appeals and dispute process of Medicare claims.
  • Processes (PDR) Provider dispute resolution claims (CMS 1500 & UB 04)
  • Proficient in rate application for outpatient PPS & inpatient DRG facility, ASC, and APC, payment methods to Medicare line of business.
  • Ability to resolve claims issues on identified processing errors and make recommendations for improvements to avoid errors.
  • Process and adjudicate claims on the date received the order. (First in, first out)
  • Resolve any grievances and complaints received through Claims Customer Service Call Center.
  • Prompt and accurate response to claims-related questions from Supervisors, and Management.
  • Identify claims that are a potential Stop Loss case.
  • Identify any overpayments or underpayments in a review and or history search. Follow department protocol for reporting and follow-up.
  • When needed assist in claims audit activities.


  • 3-4 years of hands-on experience with HMO claims functions, regulations, and guidelines.
  • High school diploma or equivalent.
  • Proficient in medical terminology, CPT, ICD9, Revenue codes, and HCPCS codes.
  • Excellent verbal and written communication skills.
  • Excellent organizational skills and interpersonal skills.
  • Experience with the EZ-CAP system for claims processing.

We’re Making Healthcare Right. Together.

We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:

**Focusing on Consumers
** We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.

**Building on Alignment
** We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.

Powered by Technology

We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.

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As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

Job Summary
  • Job Title
    Claims Examiner III
  • Company
    Bright Health
  • Location
  • Employment Type
    Full time
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