Claims Management - Claims Examiner

Virtual Req #710
Thursday, November 18, 2021

Our goals are to provide excellent service, utilize advanced technology, and proficiently deliver results. To accomplish these goals, we constantly seek individuals who look for ways to do things better. We are a company whose culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement.

Tabula Rasa HealthCare (TRHC) is a leader in providing patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize performance to improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. Medication risk management is TRHC’s lead offering, and its cloud-based software applications, including EireneRx® and MedWise™, provide solutions for a range of payers, providers and other healthcare organizations.


TRHC empowers our employees to provide excellent service, utilize advanced technology, and proficiently deliver results. Our 32Fundamentals are what we are and who we are.  Our culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement. As a part of our team, you will help us bring innovative service models to healthcare, improving patient outcomes.

Job Description:                       Claims Examiner


Summary: Under the supervision of an assigned Claims Supervisor, the Claims Examiner is responsible for processing claims and meeting defined quality and productivity standards.


Essential Functions:


Claims Processing and Payment

Evaluates claims for completeness and validity to determine payment/denial according to provider contracts, authorizations, and Medicare processing guidelines

Processes various Medicare and Medicaid claim types, including Professional, Facility and Dental claims

Accurately analyzes and interprets provider contracts

Researches claims and makes appropriate adjustments


Additional Functions:

Implements the TRHC 32 Fundamentals into daily work

Communicates clearly and concisely, with sensitivity to the needs of others

Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups; consistently cooperates and supports organization in problem solving issues; ensures customer satisfaction; will support the success of the entire team; establishes and maintains effective working relationships with co-workers

Follows all Policies and Procedures and HIPAA regulations

Maintains a safe working environment

Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees

Establishes and maintains effective working relationships with co-workers

Participates in any required training sessions/seminars

Participates in special projects as requested


Supervisory Responsibility: None


FLSA Status: Non-exempt


Travel: None


Knowledge, Skills and Abilities:

Education/Experience – Educational requirements include a high school diploma or equivalent. 

Two years of claims processing experience with an insurance company or TPA is required.  Claims processing experience with PACE or Medicare Advantage is strongly preferred.

Requires working knowledge of ICD-10, CPT, Revenue, and HCPCS coding, along with understanding of APC and DRG reimbursement.

Requires knowledge of current computer technology, including the use of computers; knowledge and proficiency with associated software, including Excel and Word

Requires flexibility and adaptability to frequently changing processes

Skilled in establishing and maintaining effective working relationships with co-workers and clients

Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency

Detail-oriented with ability to focus for extended periods

Ability to work independently, seeking supervision as needed

Ability to communicate professionally, clearly and effectively, verbally and in writing

Ability to meet attendance requirements to effectively fulfill all functions of the position

Ability to independently follow through on assigned tasks, without prompting

Ability to prioritize effectively

Ability to multitask


Physical Demands & Requirements:

Communicates by way of the telephone with participants, customers, vendors and staff

Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer

Remains stationary for extended periods of time

Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy

Frequent, repetitive use of hands/fingers entering information on a keyboard


Work Environment:

This job operates in a home office environment with a conversational noise level. 

No substantial exposure to adverse environmental conditions is expected

Moderate pressure to meet scheduled appointments and deadlines

Potential for occasional verbal aggression by clients and vendors




***This is a remote position. Adequate internet speeds and a suitable home-office environment are required for this position. All new team members will be bound by the “Teleworking Agreement’ and must continually meet the terms of the agreement to maintain remote work status.


The Company is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to ancestry or national origin, race or color, religion or creed, age, disability, AIDS/HIV, gender, marital or family status, pregnancy, childbirth or related medical conditions, genetic information, military service, protected caregiver obligations, sexual orientation, protected financial status or other classification protected by applicable law.

Other details

  • Pay Type Hourly