Medical Claims Processor

Job Description: • Analyze and process a variety of complex medical claims in accordance with program policies and procedures, ensuring accuracy and compliance. • Adjudicate claims according to program guidelines, applying critical thinking skills to navigate complex scenarios. • Ensure prompt claims processing to meet client standards and regulatory requirements. • Identify and resolve any barriers using effective problem-solving strategies. • Collaborate with internal departments to proactively resolve discrepancies and issues. • Use analytical skills to identify root causes and implement solutions. • Uphold confidentiality of patient records and company information in accordance with HIPAA regulations. • Maintain thorough and accurate records of claims processed, denied, or requiring further investigation. • Analyze and report trends in claim issues or irregularities to management. • Assist Team Leads with reporting to contribute to continuous process improvements. • Engage in audits and compliance reviews to ensure adherence to internal and external regulations. • Critically evaluate and recommend process improvements when necessary. • Mentor and train new claims processors as needed. Requirements: • High school diploma or equivalent. • Minimum of five years of experience in medical claims processing, including professional and facility claims, as well as complex and high-dollar claims. • Familiarity with ICD-10, CPT, and HCPCS coding systems. • Understanding of medical terminology, healthcare services, and insurance procedures (experience with worker’s compensation claims is a plus). • Strong attention to detail and accuracy. • Ability to interpret and apply insurance program policies and government regulations effectively. • Excellent written and verbal communication skills. • Proficiency in Microsoft Office Suite (Word, Excel, Outlook). • Ability to work independently and collaboratively within a team environment. • Commitment to ongoing education and staying current with industry standards and technology advancements. • Experience with claim denial resolution and the appeals process. • Ability to manage a high volume of claims efficiently. • Strong problem-solving capabilities and a customer service-oriented mindset. • Flexibility to adjust to the evolving needs of the client and program changes. Benefits: • 401(k) with employer matching • Health insurance • Dental insurance • Vision insurance • Life insurance • Flexible Paid Time Off (PTO) • Paid Holidays