Medical Claims Adjudicator

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

📋 Description

• Evaluate and assess claims from diverse sources to ensure accuracy and adherence to provider contracts.

• Prepare claim authorizations in conjunction with client referrals.

• Predict future claim costs for episodes of care by utilizing clinical data, prior experience, and claim management software.

• Receive, process, and compute claims payments while examining claim authorizations.

• Request and obtain additional documentation from client representatives when necessary.

• Provide clear and professional responses to phone and email inquiries from client representatives.

• Investigate discrepancies and resolve them in accordance with pricing regulations and program guidelines.

• Process claims for payment recommendations following internal procedures.

• Review electronic claims and conduct logging and data entry using medical bill repricing software and web-based tools.

• Conduct post-adjudication audits of claims as required.

• Assist in gathering statistics for management reporting purposes.

• Request and oversee the collection and storage of provider medical records as mandated by the program.

⛳️ Requirements

• High school diploma or GED is required.

• A minimum of 5 years of relevant experience.

• Proficient working knowledge of Excel.

• General understanding of claims handling processes.

• Strong written and verbal communication abilities.

• Capability to review and analyze claims effectively.

• Ability to thrive in a fast-paced environment.

• Keen attention to detail.

• In-depth knowledge of Medicare billing and reimbursement standards.

• Solid understanding of federal HIPAA regulations.

• Experience with medical claims payment and pricing systems.

• Outstanding analytical and problem-solving capabilities.

• Excellent organizational skills.

• Competence in meeting deadlines, prioritizing tasks, and remaining adaptable.

• Ability to maintain concentration despite interruptions.

• General familiarity with medical terminology and the provision of medical services.

• Proficiency in Microsoft Office applications, including Word, Excel, and PowerPoint.

• Ability to organize and analyze complex data and present it in a meaningful manner.

• U.S. citizenship is mandatory.

• Billing and/or coding certification is preferred.

• Capability to manage multiple tasks simultaneously.

• Ability to work successfully in a team-oriented environment.

• Willingness to learn quickly.

• Strong customer service orientation.

• Self-motivated individual capable of working effectively with minimal supervision.

• Ability to adapt effectively in a rapidly changing work environment and thrive in unstructured settings.

🏝️ Benefits

• Medical insurance coverage.

• Prescription drug benefits.

• Dental insurance.

• Vision insurance.

• Disability insurance.

• Retirement savings plan.

• Competitive paid time off program.

• Flexible benefits selection for employees and their dependents.

• A collegial and supportive workplace environment.

• A culture centered around teamwork, client focus, and enjoyment.