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 industry is seeking a fully remote Claims Adjudicator. The role involves processing claims, determining eligibility, and ensuring adherence to established guidelines. The position offers competitive pay, excellent growth opportunities, and a robust benefits package, including medical and retirement plans.

Benefits

Medical insurance

Pension plan

Paid Time-Off (PTO)

Flexible Spending Accounts

Tuition assistance

Qualifications

• 3-5 years in medical claim adjudication/appeals on the payor side.
• Knowledge in interpreting benefit plans including exclusions.
• Experience with medical terminology and coding processes.

Responsibilities

• Examine and verify submitted claim data within timeframes.
• Screen claims for completeness and interpret plan benefits.
• Adjudicate claims based on productivity and quality goals.

Skills

Medical coding

Eligibility verification

Coordination of benefits

ICD10

CPT codes

Job description

Healthcare Claims Adjudicator / Appeals / Insurance

Direct message the job poster from RJI Search

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

Referrals increase your chances of interviewing at RJI Search by 2x

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

Get notified about new Claims Specialist jobs in United States.

United States $55,000 - $56,000 1 week ago

California, United States $24 - $36 4 days ago

North Carolina, United States $39,696.80 - $51,605.84 2 weeks ago

United States $70,000 - $90,000 2 weeks ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.