Claims Rep III (Hlth & Dntl) (US)

CareMore Health Management Services, LLC; Cerritos (CA); On-site; USD 36,000 - 55,000; Full time

Job summary

CareMore Health Management Services, LLC is seeking a Claims Support Specialist III to perform advanced claims administration, review documentation, and resolve non-routine issues across billing, coding, clinical, and payer teams.

You will identify claim trends, reduce denials, support audits, and participate in system enhancements and process improvements to strengthen revenue cycle efficiency.

Responsibilities

• Review and validate complex healthcare claims for payer requirements and documentation standards.
• Investigate non-routine edits, denials, and discrepancies in coordination with internal teams.
• Analyze recurring issues and recommend workflow improvements to reduce denials.
• Monitor claim work queues and prioritize time-sensitive submissions.
• Support audits and quality assurance by identifying processing errors and ensuring compliance.

Job description

Job Description Summary

Responsible for facilitating the accurate and timely processing of healthcare claims by performing advanced claims administration, documentation review, and issue resolution activities. Verifies complex patient and payer information, reviews claims for completeness and compliance, manages supporting documentation, and resolves non-routine claim issues that require coordination across billing, coding, clinical, and payer teams. Supports the reduction of denials and reimbursement delays by identifying claim trends, recommending workflow improvements, and serving as an experienced resource for claims processing activities.

Claims Support Specialist III works under limited supervision to resolve non-routine operational problems and takes on projects that require analysis and cross-functional input. Decisions impact team output and the quality of administrative or operational processes. This job independently determines methods for new assignments, makes recommendations on process changes, and may informally guide entry-level employees.

How will you make an impact & Requirements

Key Responsibilities

• Review and validate complex healthcare claims to ensure compliance with payer requirements, coding references, and organizational documentation standards before submission. Investigate and resolve non-routine claim edits, denials, rejections, and documentation discrepancies by coordinating with billing, coding, clinical, and payer representatives.
• Analyze recurring claims processing issues and recommend workflow improvements that enhance claim accuracy, reduce denials, and improve reimbursement outcomes.
• Monitor claim work queues and prioritize high‑impact or time‑sensitive claims to support timely submission and resolution.
• Serve as a resource to team members by providing guidance on claims processing procedures, payer requirements, documentation standards, and system workflows.
• Support quality assurance activities by identifying processing errors, assisting with audits, and promoting adherence to revenue cycle policies and regulatory requirements.
• Participate in departmental projects, system enhancements, testing activities, and implementation of process improvements that strengthen operational efficiency.

Compensation Range: $26.40 to $39.60 The anticipated base salary range represents the Company's good‑faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.

Mosaic Health is a national care delivery platform focused on expanding access to comprehensive primary care for consumers with coverage across Commercial, Individual Exchange, Medicare, and Medicaid health plans.

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