Claims Examiner - Medicare

Medicare Claims Park Ridge, Illinois


Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Company Overview:

Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security.  Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina.  In addition, Clear Spring Health sponsors Medicare Prescription Drug plans in 42 states.

Job Summary:

The Claims Examiner adjudicates incoming claims in accordance with policies, procedures and guidelines, as outlined by Clear Spring Health and contractual agreements; within mandated timeframes; and according to rates as reflected in respective provider contracts. The Claims Examiner will be responsible for adjudicating claims from a variety of medical specialties in a timely manner to maintain turnaround time regulatory requirements.

 Main Accountabilities:

  • Enter claim data accurately and timely, in alignment with departmental production and quality goals
  • Maintain established levels for accuracy and productivity
  • Pre-screen all claim types for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding)
  • Correctly adjudicate claims for contracted/non-contracted providers; Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with contractual guidelines
  • Review respective coding (i.e. CPT, HCPCS, ICD-10) to ensure that claims are billed in compliance with CMS and Correct Coding guidelines
  • Verify presence of all required data fields and that applicable medical records are included/reviewed (where required)
  • Identify and handle third party liability (TPL) or coordination of benefits (COB) issues
  • Refer claims for medical claim review as necessary/applicable
  • Identify and refer potential fraud and abuse cases to the Compliance Department
  • Communicate identified trends to the Claims Department Supervisor for use in development of contracted provider training programs
  • Identify opportunities for claims adjudication process improvements
  • Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames 
  • Ability to read, write and communicate at a professional level 
  • Effective time management and organizational skills
  • Effective interpersonal and communication skills
  • Other duties and responsibilities as may be assigned
  • Display actions that align with our Vision, Mission, and Values


  • Associated degree preferred or equivalent experience
  • Minimum of three years’ experience in healthcare claims processing, or an equivalent combination of education, training and experience
  • Computer proficiency in a Windows environment, knowledge of Microsoft Office products
  • Detailed knowledge of electronic billing processes and universal billing forms (UB04, CMS-1500)
  • Strong knowledge of medical terminology
  • Knowledge of CPT Codes, HCPCs and ICD-10 codes
  • Medicaid and Medicare experience preferred