Claims Processor

Role Overview

• Review medical claims thoroughly to ensure no missing or incomplete information.
• Navigate multiple computer systems and platforms to research and process assigned claims accurately (e.g., verifying pricing, prior authorizations).
• Apply appropriate benefits to each claim in accordance with claims processing policies, including grievance procedures, state mandates, CMS guidelines, and benefit plan documents.
• Review documentation to assess whether the visit was necessary and whether the policy covers the treatment received.
• Determine if claims should be paid or denied, and complete denial letters when applicable.

Requirements

• Minimum of one year of recent experience processing medical claims for a health insurance company or payer.
• Familiarity with medical claim forms (CMS-1500 and UB-04).
• Working knowledge of coding systems: ICD-10, HCPCS, and CPT.
• Proficient in computer navigation and technology, including Microsoft Windows, Excel (advanced functions), and web-based tools and platforms.
• Excellent verbal and written communication skills.
• Ability to remain focused and productive in a high-volume, repetitive task environment.
• High School Diploma or equivalent.

Benefits

• Medical, Dental, and Vision coverage.
• Life Insurance.
• Short-Term and Long-Term Disability options.
• Flexible Spending Account (FSA).
• Employee Assistance Program.
• 401(k) with employer contribution.
• Paid Time Off (PTO).
• Tuition Reimbursement.