Medical Claims Examiner

The Claims Examiner – Vision Insurance is a key contributor within the Claims Department, responsible for accurately adjudicating vision and eye care claims in compliance with Medicaid, Medicare, and commercial payer guidelines. This role supports operational excellence by ensuring timely payments, regulatory compliance, and high-quality service to providers and internal stakeholders. The Claims Examiner plays an active role in meeting departmental performance metrics and supporting audits, reporting, and workflow oversight.This is a fully on-site role, and employees are expected to report to the Clifton, New Jersey office five days per week.Key ResponsibilitiesReview, evaluate, and adjudicate vision and eye care insurance claims in accordance with payer guidelines, including Medicaid, Medicare, and Coordination of Benefits (COB) rulesProcess complex or high-dollar claims requiring supervisory overridesDistribute daily claim workloads and support operational workflow efficiencyPrepare and maintain documentation for internal and external auditsEnsure compliance with prompt pay regulations and timely filing requirementsResearch and resolve rejected, denied, or pending claims, including billing corrections and resubmissionsAnalyze remittance advice (EOBs/ERAs) and communicate findings as neededSupport monthly claims reporting and departmental performance trackingCollaborate with leadership to meet monthly productivity and accuracy goalsRespond promptly and professionally to internal and external communicationsPerform additional duties as assigned to support claims operations and leadership initiativesRequired Qualifications:5+ years of experience adjudicating and processing healthcare claims, preferably in vision insurance or eye careStrong knowledge of Medicaid and Medicare claim processingProficiency with CPT, ICD-10, HCPCS codes, and modifiers, including billing and coding editsSolid understanding of Third-Party Liability (TPL) and Coordination of Benefits (COB) rulesExperience with electronic claims submission, clearinghouses, and billing resubmission processesIn-depth knowledge of HCFA-1500 (CMS-1500) and electronic billing standardsFamiliarity with appeals and reconsideration processes for government payersExperience researching and resolving claim denials and timely filing issuesWorking knowledge of AS400 or similar claims processing systemsIntermediate to advanced Microsoft Office skills, with emphasis on ExcelStrong attention to detail, analytical skills, and ability to manage deadlines in a high-volume environmentPreferred Qualifications:Previous leadership experience would be preferred Certified Professional Coder (CPC/CBC) and/or Certified Professional Biller (CPB)Prior experience in vision plans, optometry, ophthalmology, or eye care billingExperience supporting or participating in claims audits or compliance reviewsWhy Join Us?Be part of a collaborative claim’s leadership-focused environmentOpportunity to specialize in eye care and vision insurance claimsRole offers stability, growth, and exposure to complex adjudication and compliance workNational Vision AdministratorsFor over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health & Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey.Website: http://www.e-nva.comWe are an equal opportunity employerMonday - Friday 8:30am - 5:00pm