Claims Representative

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

📋 Description

• Evaluate medical records, authorization documents, and claim details to facilitate post-service medical necessity assessments.

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

• Develop and uphold authorization cases while attaching clinical documentation for review by clinical personnel.

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

• Adjudicate claims and execute claim adjustments based on authorization and clinical review findings.

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

• Generate and oversee ECRM tickets along with other operational workflows that aid in claim resolution.

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

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

• Review and process Post-Service Medical Necessity Determination claims; this position does not involve making medical necessity determinations or decisions regarding authorization approval or denial.

⛳️ Requirements

• High School Diploma or equivalent is mandatory.

• Familiarity with medical terminology is essential.

• Knowledge of CPT and ICD-10 coding is required.

• Experience in health insurance claims processing is necessary.

• Capability to interpret benefit plans and policy language.

• Proficiency in Microsoft Office Suite is required.

• Ability to operate multiple applications concurrently.

• Comfortable working in a virtual setting utilizing Teams, Outlook, Cisco WebEx, and similar tools.

• Strong attention to detail and accuracy is crucial.

• Ability to recognize discrepancies and missing information.

• Self-motivated and responsible.

• Excellent time management skills.

• Adaptability and a growth-oriented mindset.

• Effective written and verbal communication skills.

• Capability to meet productivity and quality KPIs.

• Customer-oriented service delivery is essential.

• 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 a plus.

• Preferred knowledge of medical terminology and CPT/ICD-10 coding.

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

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

• If working remotely, a cable broadband or fiber optic internet connection with a minimum of 10Mbps download and 5Mbps upload speed is required.

🏝️ Benefits

• Eligibility for an annual bonus plan.

• Medical, vision, and dental coverage starting on the first day of employment.

• Access to well-being and behavioral health programs.

• 401(k) plan.

• Company-paid life insurance.

• Tuition reimbursement opportunities.

• A minimum of 18 days of paid time off annually.

• Paid holidays.

• Leaves of absence available.

• Option for remote work arrangements.