Medicare Advantage Claims Processor - 100% remote

RAM Health; United States; Remote; USD 25,000 - 28,000; Full time

Benefits offered by this job

Remote work

Health insurance

Dental & Vision insurance

Vacation and holiday pay

401k with company match

Life insurance

AD&D

Long-term disability

HSA and FSA

Tuition reimbursement

Parental leave

Job summary

RAM Health is seeking a Claims / Encounter Specialist to review pended claims, apply business rules, and finalize decisions in line with regulatory and client expectations. You will also prepare claims data for encounters and assist with adjustments and appeals as needed.

The role requires 1–3 years in the healthcare payer space (Medicare Advantage, Managed Medicaid) with strong attention to detail, solid MS Word/Excel skills, and clear written and oral communication.

Qualifications

• 1–3 years in healthcare payer space (Medicare Advantage, Managed Medicaid)
• Experience in production environment
• Ability to apply documented procedures to achieve outcomes

Responsibilities

• Perform timely and accurate claim adjudication and adjustments
• Adjudicate specialty claims (ambulatory surgery, dental, DME, etc.)
• Prepare encounters for submission and correct rejected encounters
• Support system inquiries from member and provider call center services
• Research and review Claims Appeals information to support client inquiries
• Meet established production and quality standards
• Identify opportunities to improve efficiency within assigned processes

Skills

MS Word

MS Excel

Communication skills

Attention to detail

Education

High School Diploma

Tools

BPaaS experience

Job description

At RAM Health , our mission is to simplify the complexities of healthcare administration through innovative, technology-driven solutions. With a focus on changing the industry one plan at a time, we drive continuous innovation to help government-sponsored health plans improve performance and quality while reducing costs. RAM Health - Health plan administration, simplified. This position is fully remote and open to U.S. candidates.

The Claims / Encounter Specialist will be required to perform reviews of pended claims of all types and specialties, apply business rules and finalize claims in accordance with regulatory and client expectations. Additionally, the Specialist will review adjustment requests and determine whether to uphold the original decision or perform an adjustment of the claim to correct outcomes. This role will also be required to assist with review and preparation of claims data for submission of encounters. The specialist must have excellent analytical skills, along with keen attention to detail and good written and oral communication abilities.

Responsibilities

• Perform timely and accurate claim adjudication and adjustments
• Adjudicate specialty claims, including, but not limited to ambulatory surgery, skilled nursing, dental, anesthesia, medical assistance, reprocessed claims, duplicate claims, ambulance, durable medical equipment (DME), or institutional based charges.
• Prepare encounters for submission and correct rejected encounters
• Support system inquiries documented from the member and provider call center services
• Research and review Claims Appeals information to support client inquiries
• Meet established production and quality standards
• Identify opportunities to improve efficiency within assigned processes

Minimum Requirements

• 1-3 years in healthcare industry experience working in the payer segment in Medicare Advantage, Managed Medicaid, or working with an industry competitor.
• Experience in BPaaS environment is a plus.
• Candidate should have experience working in a production environment and the ability to meet performance standards.
• Attention to detail and the ability to apply documented procedures to achieve desired outcomes are also required.
• MS Word and MS Excel, good interpersonal skills, written and oral communication abilities a must.
• A High School Diploma is required.

Compensation and Benefits

• Competitive hourly rate commensurate with experience
• 100% remote work culture
• Health, dental & vision insurance
• Vacation and holiday pay
• Traditional and ROTH 401k with company match
• Company paid life insurance, AD&D, and long-term disability coverage
• HSA and FSA accounts
• Tuition Reimbursement
• Parental Leave

Salary: $18-$20/hour

Compliance: All employees shall comply with company policies, including those related to security and privacy, as well as with applicable laws and regulations such as the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health (HITECH) Act, and other relevant federal and state regulations. Data Protection: Employees are responsible for safeguarding protected health information (PHI) and personally identifiable information (PII) in accordance with company policies and HIPAA regulations. This includes ensuring that all data is accessed, processed, stored, and transmitted securely.