Healthcare Claim Processor

About This Opportunity

Our talent team is representing a confidential healthcare organization seeking a Healthcare Claim Processor to join their operations. This is a remote position based in the United States, offering the opportunity to work with Medicaid claims in a high-volume processing environment.

In this role, you'll be responsible for reviewing and adjudicating suspended healthcare claims, ensuring accuracy and compliance with regulatory requirements. You'll apply your knowledge of medical billing, coding, and reimbursement guidelines to resolve complex claims issues while maintaining strict confidentiality standards.

Responsibilities

• 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 Medicaid 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

What We're Looking For

• At least two (2) years of experience in Medicaid 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

How We Work with You

When you apply through Get A Job.ai, one of our experienced recruiters will review your qualifications and conduct an initial screening. If your background aligns with our client's needs, we will submit your profile for consideration. Please note that all applications must go through Get A Job.ai—do not contact the client directly, as we are managing this search exclusively.

Pay

Pay details will be discussed during the screening process with our recruiting team.

Equal Employment Opportunity: Get A Job.ai is committed to inclusive hiring practices and equal employment opportunities. We welcome applications from all qualified candidates regardless of race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status.