Claim Processor III

This is a fully remote position, open to applicants in Arizona, +16 more states.

📋 Description

• Evaluate professional and institutional medical claims from the moment of receipt through to the final decision.

• Process an average of 35 to 50 claims each day while upholding quality and productivity standards.

• Examine claims for accuracy in coding, pricing, benefit application, eligibility, and payment determination.

• Analyze intricate claim scenarios that involve coordination of benefits, member liabilities, coinsurance, copays, and balance billing.

• Detect and resolve discrepancies in claims, system issues, and irregularities in payments.

• Interpret and apply benefit plans, policies, regulatory requirements, and internal procedures effectively.

• Manage complex claims that involve substantial amounts, multiple service dates, specialized provider arrangements, and unique benefit situations.

• Utilize critical thinking and sound judgment to arrive at appropriate outcomes for claims.

• Escalate matters that require further review, coding validation, or medical assessment.

• Collaborate with coders, medical review teams, auditors, analysts, account managers, and operational partners.

• Coordinate claim research and issue resolution with internal stakeholders.

• Assist with escalated issues from members, providers, and clients that need specialized claims expertise.

• Share insights and best practices with team members.

• Process claims using HealthRules and price claims on the WebTPA platforms.

• Access external pricing and vendor portals as necessary.

• Work alongside network partners and vendors to secure pricing and claim adjudication information.

• Adhere to established Standard Operating Procedures (SOPs) and workflow documentation to ensure consistency in processing.

• Meet expectations for accuracy, turnaround time, and productivity.

• Identify trends and opportunities for improving processes and workflows.

• Maintain compliance with departmental policies and regulatory requirements.

• Contribute to team objectives and continuous improvement initiatives.

• Perform additional duties as assigned.

⛳️ Requirements

• High school diploma or equivalent qualification.

• A minimum of 3 years of experience in medical claims processing.

• Advanced understanding of healthcare claims adjudication processes.

• Experience utilizing HealthRules and/or WebTPA.

• Experience in processing commercial and Individual & Family Business (IFB) claims.

• Familiarity with provider pricing methodologies and network arrangements.

• Knowledge of Coordination of Benefits (COB).

• Understanding of medical billing and coding principles.

• Comprehension of benefit administration.

• Knowledge of coinsurance, copays, member liability, and balance billing.

• Understanding of commercial health insurance claims processing.

• Ability to interpret and comply with detailed standard operating procedures.

• Strong analytical, critical thinking, and problem-solving abilities.

• Proficiency in Microsoft Excel and Microsoft Word.

• Experience working with claim vendors, pricing systems, and external portals.

• Knowledge of healthcare operations and claims workflows.

• Primary residence in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, or WI.

• Legally authorized to work in the United States at the time of application.

• Please note, Medica does not provide work visa sponsorship for this position.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Paid Time Off (PTO).

• Holidays.

• Paid volunteer time off.

• 401K contributions.

• Caregiver services.

• Competitive total rewards package.