Claim Processor III

Job not on LinkedIn

🔥 7 minutes ago

🌵 Arizona, Florida, +15 more states – Remote

🌵 Arizona – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🌾 Nebraska – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote

💵 $37.6k - $56.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Medica

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1975

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Medica is a nonprofit health plan and insurer with over 50 years of experience that provides individual & family plans, Medicare, Medicaid, and employer-provided health plans. It offers member services and tools for finding providers, managing benefits and claims, wellness programs, and community-focused initiatives through the Medica Foundation to advance health equity.

📋 Description

• Adjudicate professional and institutional medical claims from initial receipt through final determination • Process an average of 35 to 50 claims daily while maintaining quality and productivity standards • Review claims for coding accuracy, pricing, benefit application, eligibility, and payment determination • Analyze complex claim scenarios involving coordination of benefits, member liability, coinsurance, copays, and balance billing • Identify and resolve claim discrepancies, system issues, and payment irregularities • Interpret and apply benefit plans, policies, regulatory requirements, and internal procedures • Navigate complex claims involving high-dollar amounts, multiple service dates, specialized provider arrangements, and unique benefit situations • Use critical thinking and sound judgment to determine appropriate claim outcomes • Escalate issues requiring additional review, coding validation, or medical review • Collaborate with coders, medical review teams, auditors, analysts, account managers, and operational partners • Coordinate claim research and issue resolution with internal stakeholders • Support escalated member, provider, and client issues requiring specialized claims expertise • Share knowledge and best practices with team members • Process claims within HealthRules and price claims for WebTPA platforms • Access external pricing and vendor portals as needed • Work with network partners and vendors to obtain pricing and claim adjudication information • Follow established SOPs and workflow documentation to ensure processing consistency • Meet accuracy, turnaround time, and productivity expectations • Identify trends and opportunities to improve processes and workflows • Maintain compliance with departmental policies and regulatory requirements • Contribute to team goals and continuous improvement initiatives • Perform other duties as assigned

🎯 Requirements

• High school diploma or equivalent • Minimum of 3 years of medical claims processing experience • Advanced knowledge of healthcare claims adjudication processes • Experience using HealthRules and/or WebTPA • Experience processing commercial and Individual & Family Business (IFB) claims • Familiarity with provider pricing methodologies and network arrangements • Understanding of Coordination of Benefits (COB) • Understanding of medical billing and coding concepts • Understanding of benefit administration • Understanding of coinsurance, copays, member liability, and balance billing • Understanding of commercial health insurance claims processing • Ability to interpret and follow detailed standard operating procedures • Strong analytical, critical thinking, and problem-solving skills • Proficiency with Microsoft Excel and Microsoft Word • Experience working with claim vendors, pricing systems, and external portals • Knowledge of healthcare operations and claims workflows • Primary home address in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, or WI • Legally authorized to work in the United States at the time of application • Medica does not offer work visa sponsorship for this role

🏖️ Benefits

• Medical insurance • Dental insurance • Vision insurance • PTO • Holidays • Paid volunteer time off • 401K contributions • Caregiver services • Competitive total rewards package