Overview
We are seeking a highly skilled and detail-oriented Senior Medical Claims Processor to join our team. This role requires deep expertise in medical claims processing, with a strong emphasis on accurately reviewing and adjudicating claims using standard billing forms and coding systems.

The ideal candidate will have hands-on experience processing medical claims and a thorough understanding of CMS-1500 and CMS-1450 (UB-04) claim forms, as well as proficiency in CPT and HCPCS coding. This position plays a critical role in ensuring claims are processed efficiently, accurately, and in compliance with regulatory and payer guidelines.

Key responsibilities include evaluating complex medical claims, verifying insurance and documentation, and ensuring proper coding and billing practices are followed. The Senior Examiner will also help drive quality, accuracy, and timeliness within the claims workflow while supporting compliance and operational excellence.

• Minimum of 3 years’ experience processing medical claims in the healthcare industry.
• Prior experience working with managed care, Medicare, Medicare Advantage, Health Exchange, and TRICARE are highly desirable.
• Associate's degree or equivalent job-related experience required.

This is an excellent opportunity for a subject matter expert in medical claims processing who thrives in a fast-paced environment and is committed to delivering high-quality outcomes..

Duties

• Review and evaluate complex medical insurance claims, ensuring accuracy and adherence to established policies and procedures.
• Verify insurance coverage through detailed insurance verification processes, including assessing eligibility for Medicare, Workers' Compensation, and other health plans.
• Analyze medical documentation, including medical records and reports, to determine claim validity and appropriate reimbursement levels.
• Apply medical coding principles using ICD-9, ICD-10, CPT codes, HCPCS, DRG classifications, and ICD coding standards to accurately process claims.
• Conduct thorough filing of claims documentation within electronic and physical records systems while maintaining organized records management.
• Collaborate with healthcare providers and insurance carriers to resolve discrepancies or issues related to claims adjudication.
• Ensure compliance with Workers' Compensation law and other relevant regulations during claim evaluation processes.
• Utilize financial software to process payments, track claim statuses, and generate detailed reports for management review.
• Maintain up-to-date knowledge of medical terminology, medical billing practices, and industry standards to enhance processing accuracy.

Qualifications

• Proven clerical experience with a focus on claims processing or medical billing within an insurance or healthcare setting.
• Strong organizational skills with the ability to manage multiple complex claims simultaneously while maintaining attention to detail.
• Familiarity with medical terminology, ICD-9/ICD-10 coding systems, CPT coding, HCPCS codes, DRG classifications, and ICD coding standards.
• Experience verifying insurance coverage for Medicare, Workers' Compensation law compliance, and other health plans.
• Knowledge of medical documentation review procedures and medical records management.
• Proficiency in using financial software applications for claims processing and reporting purposes.
• Excellent communication skills for effective collaboration with healthcare providers, insurers, and internal teams.
• Prior experience working with medical billing systems or electronic health records (EHR) is preferred but not required. Join our team as a Senior Processing Medical Claims Examiner to ensure the precise evaluation of claims while supporting efficient healthcare reimbursement processes through expert analysis and dedicated service!

Pay: $20.83 - $25.00 per hour

Benefits:

• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Paid time off
• Professional development assistance
• Tuition reimbursement
• Vision insurance

Application Question(s):

• Have you worked with CMS-1500 and/or CMS-1450 forms in medical claims processing? (Yes/No) If yes, please provide a brief example.
• Have you processed medical claims using CPT and HCPCS codes? If yes, how many years of experience do you have?
• Do you have experience processing or paying medical claims?

Work Location: In person