Senior Medical Claims Processor

About the Client

The organization operates in the healthcare industry, focusing on reshaping healthcare delivery for families by eliminating traditional costs such as premiums, deductibles, and out-of‑of‑pocket maximums. It addresses the financial burdens associated with healthcare by providing a model that reduces expenses for families, aiming to make healthcare more accessible and affordable.

About the Opportunity

The Senior Medical Claims Processor plays a critical role in ensuring the accurate and compliant processing of complex medical claims. This position serves as a subject‑matter expert, supports junior team members, and oversees operational workflows to ensure timely resolution of claims. The role directly contributes to maintaining high‑quality claims adjudication and improving provider relations, which are essential for the organization’s healthcare delivery model.

Responsibilities

• Review and process medical claims with high accuracy and efficiency.
• Manage manual claims and complex reprocessing.
• Analyze claims to identify discrepancies and determine appropriate adjudication.
• Interpret benefit plans, coding standards, and payer guidelines.
• Process Coordination of Benefits and non‑coordinated claims.
• Handle appeals, accident letters, and medical records requests.
• Generate and review Explanation of Benefits/Payments and no‑pay letters.
• Manage claim settlements and follow‑up on agreements.
• Investigate and resolve claim issues including eligibility and billing discrepancies.
• Handle escalations from internal teams, clients, and members.
• Respond to provider and member inquiries.
• Coordinate with other departments to resolve complex issues.
• Communicate and negotiate with providers regarding claims and payments.
• Manage payment processes including check status and adjustments.
• Oversee daily workflow to ensure timely claims processing.
• Submit physical claims to clearinghouse.
• Monitor group termination and premium payments.
• Track pending claim statuses and eligibility.
• Conduct claims audits and quality assurance.
• Ensure compliance with policies, client guidelines, and regulations.
• Maintain detailed documentation of claim decisions.
• Serve as first point of contact for team support and issue resolution.
• Mentor and train junior claims processors.
• Lead or support daily team meetings.
• Participate in quality and process improvement initiatives.

Requirements

• High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred.
• 3 to 5+ years of medical claims processing experience.
• Knowledge of medical terminology, ICD‑10, CPT, HCPCS coding, and insurance concepts.
• Experience with EHR/claims processing systems and payer platforms.
• Familiarity with Medicare, Medicaid, and commercial insurance guidelines.
• Experience with complex claims, appeals, and provider negotiations.
• Leadership or mentoring experience preferred.
• Strong analytical, problem‑solving, and communication skills.
• Ability to manage high‑volume workloads independently.
• Preferred certifications include CPC or CCS.
• Experience in auditing or quality assurance preferred.

Pay

Salary range: $50,000 – $55,000 per year.

Benefits

• Free healthcare for employee and family with no premiums, deductibles, or out‑of‑pocket maximums.
• Dental and vision insurance.
• Paid time off and sick time.
• 401(k) access.

Equal Opportunity Statement

Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.