Healthcare Claim Processor

🔥 18 hours ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $17 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.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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Qualfon

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1995

📣 Marketing

📦 Logistics

🏥 Healthcare

Marketing • Logistics • Healthcare

Qualfon is a comprehensive provider of customer engagement solutions, specializing in services such as contact center operations, digital marketing, data analytics, and fulfillment. The company focuses on enhancing customer interactions and driving revenue through a blend of innovative marketing strategies and back-office support. With a strong commitment to customer care, Qualfon aims to improve customer loyalty and satisfaction across various industries.

📋 Description

• Review and adjudicate suspended claims to ensure accurate processing and payment in accordance with established guidelines. • Confirm member eligibility, provider information, required authorizations, and covered benefits. • Evaluate medical records, claim forms, billing details, and supporting documentation to determine appropriate claim outcomes. • Identify discrepancies and resolve claim errors to ensure accurate adjudication. • Investigate and resolve claims-related issues while meeting established quality, productivity, and turnaround-time standards. • Apply Medi-Cal policies, regulations, reimbursement rules, and payment guidelines consistently and accurately. • Analyze claim information and interpret applicable policies and procedures to determine the appropriate resolution. • Safeguard protected health information and maintain compliance with HIPAA and organizational confidentiality requirements. • Partner with internal teams to address complex claims issues and escalate matters requiring additional review or resolution. • Accurately document claim reviews, actions taken, and final adjudication decisions in the appropriate systems.

🎯 Requirements

• At least two (2) years of experience in Medicaid/Medi-Cal claims processing and adjudication. • Working knowledge of healthcare claims, medical terminology, and billing practices. • Familiarity with CPT, HCPCS, and ICD-10 coding principles. • Strong attention to detail and a commitment to maintaining accuracy while meeting productivity and turnaround-time expectations. • Ability to understand, interpret, and apply policies, procedures, regulatory requirements, and payment guidelines. • Strong analytical, organizational, and time-management skills with the ability to prioritize competing tasks. • Ability to perform effectively in a high-volume, fast-paced production environment. • Excellent verbal and written communication skills. • Ability to independently research, analyze, and resolve claims issues using established guidelines and resources. • Proficiency with claims processing systems, Microsoft Office, and other computer-based applications. • Demonstrated ability to protect confidential information and appropriately handle sensitive member and provider data.