Senior Healthcare Claims Processor

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

📋 Description

• Review, assess, analyze, process, and adjudicate medical claims for professionals, facilities, complex cases, and high-dollar amounts.

• Implement program guidelines, reimbursement criteria, billing regulations, modifiers, benefit limits, regulatory standards, payer policies, and federal laws.

• Address escalated claim issues, variances, exceptions, discrepancies, denials, appeals, and complex adjudication inquiries.

• Offer daily technical support to claims processors on intricate adjudication scenarios.

• Guide and mentor claims processors and colleagues.

• Ensure precision, timeliness, compliance, privacy, data security, and adherence to service-level agreements.

• Establish and uphold claims workflows, operating procedures, escalation protocols, and quality controls.

• Convert claims policies and system regulations into consistent processing instructions.

• Suggest operational enhancements and assist in updating standard operating procedures.

• Contribute to training programs and create job aids, desk guides, examples, and knowledge-check resources.

• Identify knowledge gaps and propose specific training interventions.

• Engage in claims quality assessments, calibration meetings, audits, and root-cause analyses.

• Record claim decisions and assist with internal and external audit requests.

• Observe emerging trends and recommend modifications to training, processes, or system regulations.

⛳️ Requirements

• A minimum of 5 years of practical experience in processing medical professional and facility claims, including complex and high-dollar claims.

• Strong knowledge of ICD-10, CPT, HCPCS, revenue codes, and modifiers.

• Comprehensive understanding of the entire claim lifecycle: intake, review, adjudication, reimbursement, adjustments, denials/rejections, and escalations.

• Proven experience in interpreting and applying payer policies and federal regulations.

• Experience in resolving claim denials, appeals, and complex adjudication inquiries.

• High level of accuracy in fast-paced environments.

• Strong analytical and problem-solving capabilities.

• Proficiency in Microsoft Office and claims processing software.

• Ability to understand and apply program policies, payer regulations, and federal guidelines.

• Dedication to continuous training and remaining updated on industry standards, technology, and regulatory changes.

• Experience with workflows related to claim denial resolutions and appeals.

• Strong customer-service orientation.

• MBI (T2) public trust or other necessary clearance.

🏝️ Benefits

• Options for medical plans, including those with Health Savings Accounts.

• Options for dental plans.

• Vision plan availability.

• 401(k) plan featuring pre-tax and post-tax contributions along with company matching.

• Flexible work weeks where feasible.

• Paid vacation, sick leave, and personal time.

• Paid holidays.

• Paid parental, military, bereavement, and jury duty leave.

• Typically 15 days of paid leave each calendar year.

• Generally 10 paid holidays annually.

• Up to 160 hours of paid family leave within a rolling 12-month period for eligible employees.

• Short- and long-term disability benefits.

• Life insurance coverage.

• Accidental death and dismemberment insurance.

• Personal accident insurance.

• Critical illness insurance.

• Business travel and accident insurance.

• Remote work opportunities.

• Identity verification and security processes utilizing advanced biometrics and artificial intelligence.