Healthcare Claims Adjudicator / Appeals / Insurance

RJI Search; United States; Remote; USD 55,000 - 56,000; Full time

Job summary

A leading company in the healthcare sector is seeking a Claims Adjudicator to work remotely after a paid onsite training. The role involves reviewing, verifying, and processing claims, while ensuring adherence to established guidelines. Candidates with 3-5 years of medical claim adjudication experience are encouraged to apply for competitive pay and extensive benefits.

Benefits

Medical insurance

Dental insurance

Vision insurance

401(k) and Pension Plan

Tuition assistance

Flexible Spending Accounts

Paid Time-Off (PTO)

Paid Holidays

Short- & Long-term Disability

Employee Assistance Program

Qualifications

• Minimum 3-5 years in medical claim adjudication.
• Experience with ICD10 and CPT codes.
• Strong understanding of insurance environments.

Responsibilities

• Review and adjudicate claims to determine payment.
• Interpret plan benefits from Summary Plan Description.
• Evaluate claims for completeness and accuracy.

Skills

Medical coding

Eligibility verification

Coordination of benefits

Customer service

Education

3-5 years direct experience in medical claim adjudication

Working knowledge of benefit plan interpretation

Job description

Healthcare Claims Adjudicator / Appeals / Insurance

Healthcare Claims Adjudicator / Appeals / Insurance

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This is a fully remote role, but does require onsite training for 1 week, fully expense paid by company. Once training is completed, fully remote permanently.

Claims Adjudicator - $24.97 Hourly plus tons of growth and amazing benefits, company culture, stability and growth!

The Claims Adjudicator II position will receive, examine, verify and input submitted claim data, determine eligibility status, and review and adjudicate claims (calculate the final bill to the policy holder, on the payer side) within established timeframes.

DUTIES

• Screens claims for completeness of necessary information
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
• Codes basic information and selects codes to determine payment liability amount
• Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the claim filed, and the appropriateness or frequency of care rendered
• Determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
• Handles the end to end process of Medicare Secondary Payer (MSP) files
• Requests overpayment refunds, maintains corresponding files and performs follow-up actions
• Handles verbal and written inquiries received from internal and external customers
• Adjudicates claims according to established productivity and quality goals
• Achieve individual established goals in order to meet or exceed departmental metrics

QUALIFICATIONS

• 3 ~ 5 years of direct experience minimum in a medical claim adjudication/appeals working in an insurance environment (on the payor side/insurance side)
• Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Experience with eligibility verification, medical coding, coordination of benefits, and subrogation and it’s related processes
• Experience with medical terminology, ICD10 and Current Procedural Technology (CPT) codes

We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), AND Pension Plan, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  General Business

• Industries

  Hospitals and Health Care and Insurance

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Inferred from the description for this job

Medical insurance

Vision insurance

401(k)

Pension plan

Paid maternity leave

Paid paternity leave

Tuition assistance

Disability insurance

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