Claims Examiner

Senior Claims Examiner – Medical Claims

Location: Irving, TX
Work Arrangement: Onsite
Duration: 3-Month Contract
Schedule: Monday–Friday, 40 hours per week

Sigma Inc. is seeking an experienced Senior Claims Examiner for an onsite contract opportunity in Irving, TX. This position is ideal for an experienced healthcare claims professional with hands-on experience processing and adjudicating medical claims within a health insurance, managed care, or payer environment.

The Senior Claims Examiner will review and resolve complex medical claims, including claims submitted on CMS-1500 and CMS-1450/UB-04 forms, while maintaining established productivity, quality, and regulatory standards.

Responsibilities

• Review, process, and adjudicate complex medical claims.
• Process claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms.
• Review claims from hospitals, physicians, laboratories, home health agencies, DME providers, and other healthcare providers.
• Research and resolve claim edits, pends, discrepancies, and processing issues.
• Process claim adjustments, provider refunds, member reimbursements, overpayments, and recoveries as applicable.
• Apply medical terminology and CPT, HCPCS, ICD-10, DRG, and Revenue Code knowledge during claims review.
• Review benefit, reimbursement, and claim information to determine appropriate claim disposition.
• Research complex claims while ensuring compliance with applicable policies and healthcare regulations.
• Communicate with providers, members, and internal departments regarding claim issues and resolution.
• Collaborate with teams such as Provider Data, Network Management, Appeals, Business Configuration, and Customer Service.
• Identify claims-processing trends and assist with workflow and process improvements.
• Assist with training, mentoring, system testing, or implementation activities as needed.
• Maintain compliance with HIPAA and PHI requirements.
• Meet established productivity and quality standards.

Qualifications

• 3+ years of hands-on medical claims processing/adjudication experience within a health insurance, managed care, TPA, or similar payer environment.
• Experience processing CMS-1500 and/or CMS-1450/UB-04 claims.
• Strong knowledge of medical terminology and healthcare claims processing.
• Working knowledge of CPT, HCPCS, ICD-10, Revenue Codes, and DRGs.
• Experience researching and resolving complex claim issues, adjustments, and payment discrepancies.
• Knowledge of healthcare reimbursement methodologies and claims payment processes.
• Experience with Medicare, Medicare Advantage, Medicaid, managed care, Health Exchange, or TRICARE is highly desirable.
• Strong analytical, data-entry, organizational, and problem-solving skills.
• Proficiency with Microsoft Office, including Excel, Word, Outlook, and PowerPoint.
• Associate degree or equivalent combination of education and relevant experience.
• Ability to work onsite in Irving, TX for the duration of the assignment.

Important: This position requires hands-on medical claims processing/adjudication experience. Experience limited primarily to medical billing, claims reporting, insurance verification, provider collections, or revenue-cycle follow-up may not meet the requirements of this position.