Medical Claims Processor

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

📋 Description

• Accurately review, enter, and process professional, institutional, and/or ancillary medical claims in accordance with productivity and quality benchmarks.

• Adjudicate claims based on plan benefits, provider contracts, coordination of benefits regulations, and legal requirements.

• Investigate and resolve claims that are pending, denied, duplicated, or flagged for edits.

• Confirm member eligibility, provider details, service information, diagnosis/procedure codes, and readiness for payment.

• Utilize Medicare, Medicaid, and/or commercial payer guidelines to ascertain claim outcomes.

• Manage appeals, adjustments, voids, and resubmissions effectively.

• Navigate claims queues and designated work lists to achieve productivity objectives and minimize backlog.

• Collaborate with provider relations, member services, and quality assurance teams to address claim discrepancies.

• Record claim actions and resolutions to ensure audit preparedness and compliance.

• Detect patterns in claim errors or denials and escalate systemic issues as necessary.

• Manage protected health information in line with HIPAA privacy and security regulations.

⛳️ Requirements

• A high school diploma or equivalent is required; an Associate's or Bachelor's degree in a relevant field is preferred.

• 1–3 years of experience in medical claims processing, healthcare billing, or a similar payer/provider operations role.

• Proficient understanding of ICD-10, CPT, and HCPCS coding systems.

• Familiarity with Medicare and/or Medicaid claims guidelines.

• Experience with claims adjudication systems (e.g., QNXT, TriZetto, FACETS, or comparable platforms).

• Proficient in Microsoft Excel and standard office software.

• Exceptional attention to detail with the capability to maintain accuracy in a high-volume setting.

• Consistently meet productivity benchmarks (e.g., claims processed per hour/day).

• Strong written and verbal communication abilities.

• Experience with coordination of benefits (COB) and subrogation is preferred.

• Knowledge of managed care, HMO, PPO, and fee-for-service reimbursement methodologies (e.g., DRG, APC, APG, MS-DRG) is preferred.

• Familiarity with HRSN (Health-Related Social Needs) or non-traditional social-care claims is preferred.

• Previous experience processing appeals, reconsiderations, and high-dollar claims is preferred.

• Prior experience with Power BI, SQL, or data reporting tools is preferred.

• CPC, CPMA, or other relevant coding/billing certifications are preferred.

• Experience in a BPO or outsourced claims processing environment is preferred.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• 401(k) plan with employer matching.

• Generous paid time off and holiday policy.

• Opportunities for professional development and advancement.