Medical Claims Processor

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🔥 4 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟢 Junior

📋 Claims Specialist

🚫👨‍🎓 No degree required

👻 Ghost score 15%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Catalyst Solutions

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1999

🏥 Healthcare

💼 Consulting

🤝 B2B

Healthcare • Consulting • B2B

Catalyst Solutions is a provider of cost‑effective, intelligent business solutions exclusively to health plans, with over 25 years of experience. It offers consulting for plan strategy, operations, and technology; AI enablement; and business process outsourcing (claims, contact center, enrollment, configuration, administrative & general) delivered on its Catalyze platform or integrated with client systems. Its specialties include enterprise architecture, IT consulting, managed services, payer core systems and configurations (Facets, QNXT, Tapestry, HealthRules), clinical and care management, medical management, and systems performance optimization for managed care organizations and health plan operations.

📋 Description

• Review, enter, and process professional, institutional, and/or ancillary medical claims accurately within productivity and quality standards • Adjudicate claims according to plan benefits, provider contracts, coordination of benefits rules, and regulatory requirements • Research and resolve pended, denied, duplicate, and edit-flagged claims • Validate member eligibility, provider information, service details, diagnosis/procedure codes, and payment readiness • Apply Medicare, Medicaid, and/or commercial payer guidelines to determine claim outcomes • Process appeals, adjustments, voids, and resubmissions • Work claims queues and assigned work lists to meet productivity targets and reduce backlog • Coordinate with provider relations, member services, and quality assurance teams to resolve claim exceptions • Document claim actions and resolutions for audit readiness and compliance • Identify claim error or denial patterns and escalate systemic issues • Handle protected health information in compliance with HIPAA privacy and security requirements

🎯 Requirements

• High school diploma or equivalent required; Associate's or Bachelor's degree in a related field preferred • 1–3 years of experience in medical claims processing, healthcare billing, or a related payer/provider operations role • Working knowledge 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 similar platforms) • Proficiency in Microsoft Excel and standard office applications • Strong attention to detail with the ability to maintain accuracy in a high-volume environment • Ability to meet productivity standards (e.g., claims per hour/day) consistently • Strong written and verbal communication skills • Experience with coordination of benefits (COB) and subrogation preferred • Knowledge of managed care, HMO, PPO, and fee-for-service reimbursement methodologies (e.g., DRG, APC, APG, MS-DRG) preferred • Familiarity with HRSN (Health-Related Social Needs) or non-traditional social-care claims preferred • Experience processing appeals, reconsiderations, and high-dollar claims preferred • Prior experience with Power BI, SQL, or data reporting tools preferred • CPC, CPMA, or other relevant coding/billing certification preferred • Experience in a BPO or outsourced claims processing environment preferred

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