Medicare/Medicaid Claims Reimbursement Specialist

Commonwealth Care Alliance; Myrtle Point (OR); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a driven individual for a role focused on analyzing Medicaid and Medicare claim reimbursements. This position offers the opportunity to work remotely while ensuring compliance with healthcare regulations. The ideal candidate will have 3+ years of experience in claims processing and strong analytical skills. Join a collaborative team dedicated to improving provider relations and compliance standards.

Qualifications

• Minimum of 3+ years in healthcare claims processing.
• Experience with core claims platforms.
• Effective verbal and written communication skills.

Responsibilities

• Analyze claim reimbursements for compliance.
• Resolve provider inquiries regarding pricing.
• Document research findings in claims systems.

Skills

Healthcare claims processing

Data analysis

Provider reimbursement

Analytical skills

Communication skills

Education

Associate’s or Bachelor’s degree in Health Administration

Tools

Excel

Facets

QNXT

Amisys

Job description

Employer Industry: Healthcare Claims and Reimbursement

Why consider this job opportunity

• Opportunity for career advancement and growth within the organization
• Work remotely from Massachusetts
• Engaging role as a subject matter expert in Medicaid and Medicare reimbursement methodologies
• Collaborative environment with cross‑departmental teamwork
• Chance to impact provider relations and improve compliance standards

Job Responsibilities

• Analyze MassHealth and Medicare claim reimbursements for compliance with regulations and internal policies
• Resolve provider inquiries and disputes regarding pricing and contract interpretation
• Collaborate with various teams to validate and address reimbursement concerns
• Conduct audits to identify payment issues and recommend resolutions
• Document research findings and outcomes in claims systems in compliance with audit standards

Required Qualifications

• Minimum of 3+ years in healthcare claims processing, provider reimbursement, or payment integrity
• Experience with core claims platforms such as Facets, QNXT, or Amisys
• Proficiency with Excel and reporting tools for data analysis
• Strong problem‑solving and analytical skills
• Effective verbal and written communication skills with internal stakeholders and providers

Preferred Qualifications

• Associate’s or Bachelor’s degree in Health Administration, Finance, or a related field
• Certified Professional Coder (CPC) or Certified Claims Professional (CCP)
• Prior experience with MassHealth and Medicare Advantage reimbursement rules
• Knowledge of Facets, MassHealth, and CMS is a plus

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