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 NB to join our team!

What you’ll be doing?

• Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim.
• Reviews, processes and analyzes information necessary for processing on all high dollar claims.
• Assists with transplant cases and claims processing when applicable.
• Resolves problematic claims with the assistance of the Team Leader, Department Manager and others, as needed.
• Assists with specialized claims processing, as assigned
• Assists with specialized void/correction processing, as assigned.
• Verifies the accuracy of the refund amount and accurately processes refunds and claims corrections as directed.
• Thoroughly researches and completes intermediate level claims and claims corrections in a timely manner.
• Process eligible claims, refunds, and corrections
• Documents and convey decisions with accuracy.
• Assists with training and auditing needs within the department as needed.
• Assists the Legal Department with subrogation claims as necessary.
• Assists with audits as needed.
• Assists with plan benefit set-up and changes as needed.
• Serve as an escalation point for claims that cannot be resolved by Level I or Level II processors, ensuring accurate and timely resolution.
• 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 audit/compliance principles.
• 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.
• 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.

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.