Medical Claims Reviewer

TEEMA Solutions Group; Dallas (TX); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare solutions provider is seeking a detail-oriented Medical Claims Reviewer. In this remote role, you will conduct thorough evaluations of medical claims, ensuring compliance with relevant guidelines. The ideal candidate has a high school diploma, experience in claims review, and exceptional analytical skills, to contribute effectively within a collaborative team environment.

Qualifications

• At least 2 years of experience reviewing medical claims.
• Understanding of medical and institutional claims workflows.
• Proficiency in coding practices and attention to detail required.

Responsibilities

• Review and evaluate medical claims for accuracy based on clinical standards.
• Verify adherence to program guidelines.
• Collaborate with teams to provide coding-related insights.

Skills

Attention to detail

Analytical skills

Communication

Education

High School Diploma or GED

Tools

Claims review software

Job description

Job Title: Medical Claims Reviewer
Pay: $26-30/hour - Contract to Hire

Location: Remote

Shift: First(Monday-Friday 8 AM-5 PM)

Position Overview:
We are looking for a skilled and detail-focused Medical Claims Reviewer to perform comprehensive reviews of medical, surgical, and behavioral health claims for inpatient and outpatient services. This role involves using your clinical expertise, coding proficiency, and claims processing knowledge to assess and approve claims accurately and efficiently. You will ensure claims are aligned with program benefits and assist various stakeholders by providing coding-related insights and resolving inquiries related to claims processes.

Primary Responsibilities:

Review and evaluate medical, surgical, and behavioral health claims retrospectively for both inpatient and outpatient care.

Utilize clinical knowledge and coding standards to validate claims and ensure accurate processing.

Gather and prepare the necessary documentation for case payments and approvals.

Verify adherence to program guidelines, benefits, and authorizations.

Collaborate with medical directors, peer reviewers, Claims Administration, and other departments to share relevant clinical and coding information.

Act as a resource for staff on coding and claims-related questions.

Qualifications:

High School Diploma or GED (Required).

At least 2 years of experience reviewing medical claims.

Comprehensive understanding of medical and institutional claims workflows.

Strong grasp of medical coding practices and claims evaluation processes.

High attention to detail with strong analytical and critical-thinking skills.

Effective communication skills and the ability to work across teams.

Proficiency in claims review software and related tools.