Claims Examiner II

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 II to join our team!

What you’ll be doing?

• Review, research, and adjudicate healthcare claims (professional, institutional, dental, vision) based on plan documents, contracts, and applicable regulations (e.g., CMS, HIPAA).
• Process claims using standard claim forms (CMS-1500, UB-04, ADA) and appropriate coding systems (ICD-10, CPT, HCPCS, Modifiers).
• Resolve system pends, edits, and denials through investigative research and documentation.
• Apply proper payment methodologies including fee schedules, capitation, COB, and other reimbursement rules.
• Update provider records to ensure accurate claims routing and payment
• Process updates to member information in alignment with system rules and business requirements
• Independently manage assigned claims to meet turnaround time and quality standards
• Respond to inquiries or escalations, including shared email inboxes, within established SLAs.
• Accurately document actions and resolutions in claim systems, ensuring transparency and audit readiness.
• Collaborate with internal departments to resolve cross-functional claim issues.
• Maintain updated knowledge of client-specific workflows, benefit plans, policies, and procedures.
• Support process improvement activities, peer review tasks, and training efforts as needed.
• Ensure compliance with data privacy standards and internal security protocols (HIPAA, etc.).
• Participate in department meetings, calibration sessions, and continuing education.
• Flexible working in any shift.
• Adaptive to work on any project.
• Work from office is mandatory.

The duties set forth above are essential job functions for the role.

Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

What we’re looking for?

Required skills:

• High school diploma or equivalent required
• 2+ year(s) of experience in healthcare claims processing