Claims Representative

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct reviews of medical records, authorization documents, and claims information for post-service medical necessity assessments.

• Confirm member eligibility, benefits, coverage, authorizations, and claim requirements.

• Develop and maintain authorization cases.

• Acquire and attach clinical documentation for evaluation by clinical staff.

• Process claims related to Radiology, Pain Management, Lab, Gastro, and other specified areas in accordance with established policies and procedures.

• Evaluate claims and process adjustments based on authorization and clinical review results.

• Investigate and resolve claim discrepancies, missing information, and pending claims inventories.

• Create and manage ECRM tickets and operational workflows to facilitate claim resolution.

• Ensure adherence to client requirements, benefit plans, policies, and regulatory standards.

• Achieve set productivity, quality, and service performance goals.

• Review and process Post Service Medical Necessity Determination claims without making decisions regarding medical necessity determinations or authorization approvals/denials.

⛳️ Requirements

• High School Diploma or equivalent is mandatory.

• Preferred working knowledge of medical claims processing, provider issue resolution, and healthcare operational workflows.

• Experience with MC400, ICE, NASCO, ImageOne, Outlook, Microsoft Excel, and Microsoft Word is advantageous.

• Familiarity with medical terminology and CPT/ICD-10 coding is preferred.

• Knowledge of medical terminology.

• Understanding of CPT and ICD-10 coding.

• Experience in health insurance claims processing.

• Capability to interpret benefit plans and policy language.

• Strong attention to detail and accuracy.

• Ability to identify discrepancies and missing information.

• Proficient in Microsoft Office Suite.

• Ability to navigate multiple applications simultaneously.

• Comfortable working in a virtual environment using Teams, Outlook, Cisco WebEx, and similar platforms.

• Self-motivated and accountable.

• Strong time management skills.

• Adaptable with a growth mindset.

• Effective written and verbal communication skills.

• Ability to meet productivity and quality KPIs.

• Customer-focused service delivery.

• Proven ability to collaborate effectively across operational, provider, program, and client-facing teams.

• Demonstrated ability to manage multiple priorities while upholding quality and productivity standards.

• For remote work, a cable broadband or fiber optic internet service with a minimum of 10Mbps download and 5Mbps upload speed is required.

🏝️ Benefits

• Eligibility for an annual bonus plan.

• Medical insurance coverage.

• Vision insurance coverage.

• Dental insurance coverage.

• Access to well-being and behavioral health programs.

• 401(k) retirement plan.

• Company-paid life insurance.

• Tuition reimbursement opportunities.

• A minimum of 18 days of paid time off each year.

• Paid holidays.

• Leaves of absence.

• Remote work/home-based arrangement available.

• Requirement for cable broadband or fiber optic internet for home work.