Remote Claims Specialist III: Complex Medical Adjudication

Medica; United States; Remote; USD 38,000 - 64,000; Full time

Job summary

Medica is seeking a remote Claims Processor III to adjudicate complex commercial and IFB medical claims from receipt through final determination. You’ll apply advanced claims knowledge, interpret benefit plans, and collaborate with coders, auditors, and providers to ensure accurate outcomes.

Requirements include a high school diploma and 3+ years of medical claims processing experience. HealthRules and WebTPA experience are preferred, with strong analytical and problem-solving skills in a

Qualifications

• High school diploma or equivalent.
• Minimum of 3 years of medical claims processing experience.
• Experience with HealthRules and/or WebTPA.

Responsibilities

• Adjudicate professional and institutional medical claims from initial receipt through final determination.
• Process 35 to 50 claims daily while maintaining quality and productivity standards.
• Review claims for coding accuracy, pricing, benefit application, eligibility, and payment determination.
• Collaborate with coders, medical review teams, auditors, analysts, account managers, and vendors.

Skills

Analytical thinking

Critical thinking

Problem solving

Team collaboration

Education

High school diploma

Tools

HealthRules

WebTPA

Pricing portals

Microsoft Excel

Microsoft Word

Job description

Medica is seeking a remote Claims Processor III to adjudicate complex commercial and IFB medical claims from receipt through final determination. You’ll apply advanced claims knowledge, interpret benefit plans, and collaborate with coders, auditors, and providers to ensure accurate outcomes.

Requirements include a high school diploma and 3+ years of medical claims processing experience. HealthRules and WebTPA experience are preferred, with strong analytical and problem-solving skills in a