Healthcare Claim Processor

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

📋 Description

• Review and adjudicate suspended claims to guarantee precise processing and payment in line with established guidelines.

• Verify member eligibility, provider details, required authorizations, and covered benefits.

• Assess medical records, claim forms, billing information, and supporting documentation to ascertain suitable claim outcomes.

• Detect discrepancies and rectify claim errors to ensure precise adjudication.

• Investigate and resolve claims-related issues while adhering to established quality, productivity, and turnaround-time standards.

• Consistently and accurately apply Medi-Cal policies, regulations, reimbursement rules, and payment guidelines.

• Analyze claim data and interpret relevant policies and procedures to determine the appropriate resolution.

• Protect protected health information and uphold compliance with HIPAA and organizational confidentiality standards.

• Collaborate with internal teams to tackle complex claims issues and escalate cases necessitating further review or resolution.

• Maintain accurate documentation of claim reviews, actions taken, and final adjudication decisions in the appropriate systems.

⛳️ Requirements

• Minimum of two (2) years of experience in Medicaid/Medi-Cal claims processing and adjudication.

• Solid understanding of healthcare claims, medical terminology, and billing practices.

• Familiarity with CPT, HCPCS, and ICD-10 coding principles.

• Exceptional attention to detail and a dedication to maintaining accuracy while achieving productivity and turnaround-time goals.

• Capability to understand, interpret, and apply policies, procedures, regulatory requirements, and payment guidelines.

• Strong analytical, organizational, and time-management skills with the ability to prioritize competing tasks effectively.

• Ability to perform successfully in a high-volume, fast-paced production environment.

• Excellent verbal and written communication skills.

• Proficient in independently researching, analyzing, and resolving claims issues using established guidelines and resources.

• Skilled in claims processing systems, Microsoft Office, and other computer-based applications.

• Proven ability to safeguard confidential information and manage sensitive member and provider data appropriately.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and career advancement.

• Supportive work environment with a focus on employee well-being.