Claims Specialist - 287456

Medix™; United States; On-site; USD 50,000 - 70,000; Full time

Job summary

Medix™ is seeking a highly organized Claims Specialist in the United States to support clinical reviews and appeal adjudication programs. You'll act as a liaison between healthcare plans, providers, and patients, ensuring claims are processed efficiently and accurately.

The ideal candidate should have at least 2 years of experience in healthcare administration and possess strong communication and problem-solving skills. This position offers an excellent opportunity to contribute to a collaborative healthcare team.

Qualifications

• Minimum of 2 years of experience in healthcare administration, claims processing, or a comparable environment.
• Strong analytical and problem-solving skills with effective collaboration in teams.
• Ability to work independently while managing multiple priorities.

Responsibilities

• Serve as the primary point of contact for appeal and dispute adjudication programs.
• Monitor appeal and dispute status updates through client portals.
• Mentor and train new team members on workflows and departmental processes.

Skills

Problem-solving

Communication skills

Analytical skills

Organizational skills

Education

Associate's or Bachelor's degree in Healthcare Administration or related field

Tools

Collaborative project management software

Electronic document management systems

Job description

We are seeking a highly organized and detail-oriented Claims Specialist to support the successful execution of clinical review and appeal/dispute adjudication programs. In this role, you will serve as a key liaison between healthcare plans, providers, patients, and internal clinical teams while ensuring claims and appeals are processed efficiently, accurately, and in accordance with contractual requirements.

The ideal candidate is a proactive problem solver with healthcare administrative or claims experience, exceptional communication skills, and the ability to manage multiple priorities in a fast-paced environment.

Key Responsibilities

• Serve as the primary point of contact for appeal and dispute adjudication programs.
• Coordinate requests, correspondence, and case documentation between healthcare plans, providers, patients, clients, and internal stakeholders.
• Monitor appeal and dispute status updates through client portals and communication channels.
• Conduct initial eligibility reviews and recommend appropriate courses of action to internal teams and department leadership.
• Track, assign, and manage claims and cases using commercial and proprietary software applications.
• Review and distribute case documentation to billers, coders, nurses, physicians, clinicians, and other key stakeholders to facilitate clinical and coding reviews.
• Monitor key performance indicators, including timeliness, quality standards, accuracy, and contract deliverables.
• Identify workflow barriers and operational challenges, recommend process improvements, and implement approved solutions.
• Present case and project status updates during team huddles and agile scrums.
• Schedule team meetings, document action items, and track assigned tasks through completion.
• Prepare billing invoices upon case completion, submit documentation to the Finance department, and coordinate with Accounting to monitor payment status and trends.
• Mentor and train new team members on workflows, case progression, and departmental processes.
• Perform additional duties and special projects as assigned.

Qualifications

• Associate's or Bachelor's degree in Healthcare Administration, Business, Management, Digital Studies, or a related field preferred.
• Minimum of 2 years of experience in healthcare administration, claims processing, medical billing, insurance appeals, or a comparable healthcare environment.
• Experience using collaborative project management software and electronic document management systems.
• Strong analytical and problem-solving skills with the ability to collaborate effectively across multidisciplinary teams.
• Excellent written and verbal communication skills, including professional phone etiquette.
• Ability to work independently with minimal supervision while managing multiple priorities.
• Flexible, innovative, and adaptable with exceptional organizational skills.
• Demonstrated ability to meet deadlines and thrive in a fast-paced, time-sensitive environment.

Preferred Qualifications

• Experience supporting medical claims, appeals, utilization management, or dispute resolution processes.
• Familiarity with healthcare operations, medical documentation, coding review workflows, and provider relations.
• Knowledge of healthcare payer systems and claims adjudication processes.
• Experience working within agile or project-based team environments.

Why Join Our Team?

This is an excellent opportunity to contribute to a collaborative healthcare team dedicated to improving claims accuracy and supporting high-quality clinical review processes. You'll play a vital role in ensuring efficient case management while partnering with healthcare professionals and key stakeholders to achieve successful outcomes.