Claims Examiner III

Smart Data Solutions, a leading provider of data management, claim routing and workflow solutions to health plans and TPAs, is looking for a Claims Examiner III Stop Loss to join our team!

What you’ll be doing?

• Submission of Specs (running reports and gathering necessary documentation), email correspondence, Post reimbursements received. Answer carrier questions, and fill requests for additional information on spec filings. Coordination of all additional outside vendor and carrier discount negotiations.
• Coordinate Advance Funding. Including but not limited to review and cross-reference Accounting reports, prompt pay spreadsheet, vendor negotiations, group information details, to report to Accounting groups eligible for AF. Follow AF requests for receipt of carrier payment. Outreach to carriers I cases of Prompt pay to ensure turnaround.
• Answer carrier questions generated by the weekly inpatient high dollar email and dialysis report, 50% notifications and reimbursement requests being audited etc. This can often require working with other departments such as Claims, Enrollment, COBRA Services, Accounting and Marketing.
• Generation and preparation of monthly aggregate reports, analyzes data, and files requests for aggregate reimbursement when necessary. Works with auditor throughout the aggregate audit gathering and supplying requested information and answering auditor questions.
• Maintains a database of all information pertaining to specific and aggregate requests and receipt of reimbursements as well as importing and manual entry of 50% notifications.
• Monitors all reinsurance requests to ensure receipt of reimbursement. Generates weekly outstanding reimbursement report and follows up with carrier(s).
• Organize renewals including but not limited to making phone calls, running reports, reviewing pre-certs and confirming transmission to network
• Coordination of Benefits (COB) Proactive outreach for filing support. Coordinates with COB team
• Work Status/Eligibility retrieval. Works directly with the Enrollment team to obtain documentation indicating eligibility has been maintained for reimbursement purposes.
• Coordinates all external audit requests by gathering (or directing appropriate parties) to gather the requested information for pre-audit work; reviews all information being provided for accuracy and appropriateness. Works directly with the auditor and claims department if there are questions during the claims review. Obtains all supporting documentation relevant to the claims selection. Scheduling and attending the exit interview and preparing a final internal report of the outcome.
• Gathers information for submission to underwriters for renewals. This includes coordinating with case managers and Marketing to compile all necessary information regarding lasers and large / potentially large claims, reviews individual claims histories, obtaining supporting records when necessary to argue against potential lasers or contract limitations.
• New group implementation.
• Carrier and Vendor negotiations.
• Additional tasks as assigned.
• Ensure compliance with all client requirements, regulatory guidelines, and internal policies, including HIPAA.
• Flexible working in any shift & performing other duties as assigned.
• Work from office is mandatory

The duties set forth above are essential job functions for the role. Reasonable accommodation may be provided to enable individuals with disabilities to perform essential job functions.

Skills and Qualifications

• Bachelor’s degree or equivalent experience
• Minimum 5+ years of experience in healthcare claims examining and/or audit/compliance.
• Proven ability to handle complex claims scenarios, including COB, appeals, and high-dollar claims.
• Ability to mentor and support junior team members in a production environment.
• Advanced knowledge of ICD-10, CPT, HCPCS coding, and claims processing best practices.
• Knowledge of medical claim forms (e.g., HCFA, CMS-1500, UB-04, ADA) and familiarity with Medicare/Medicaid program requirements.
• Ability to read and interpret Standard Operating Procedure (SOP) documents, job aids, and edit resolution guidance to support occasional direct claims processing.
• Strong analytical skills with the ability to identify discrepancies, trends, and root causes from data and documentation.
• Proficiency with claims systems and Microsoft Office tools
• Strong written and verbal communication skills.
• Ability to work independently and as part of a team in a high-volume, deadline-driven environment.
• High attention to detail and organizational skills; ability to manage multiple audits and deadlines simultaneously.
• Preferred: experience in a large health plan or third-party administrator (TPA) environment.

Who is Smart Data Solutions?

Smart Data Solutions (SDS) is a technology leader in healthcare process automation and interoperability. As a strategic partner, SDS helps clients digitally transform their operations, delivering tangible value through reduced costs, streamlined workflows, and an improved customer experience. With data, AI, and automation at its core, SDS provides solutions in Digital Mailroom and Data Capture, Clearinghouse, Intelligent Medical Records, Prior Authorization and Claim Operations. Trusted by over 500 clients—including multiple Blue Cross Blue Shield plans, regional health plans, TPAs, providers, and healthcare partners—SDS streamlines complex front, middle, and back-office operations.

Smart Data Solutions is an equal opportunity employer.

All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, age, marital status, pregnancy, genetic information, or other legally protected status.