Remote Health Plan Claims Specialist

TalentLNX LLC; Northern (KY); Remote; USD 46,000 - 66,000; Full time

Job summary

TalentLNX LLC is seeking a Health Plan Claims Examiner for a fully remote U.S. role. You will adjudicate medical, surgical, and ancillary claims, applying multiple reimbursement methods, while ensuring COB compliance and timely processing.

Ideal candidates have at least 2 years of claims adjudication experience, familiarity with Facets/QNXT/HealthEdge, and solid knowledge of CPT, ICD-10, HCPCS, and CMS rules. Remote, full-time, with standard business hours.

Qualifications

• High school diploma required; associate degree in healthcare or business preferred.
• Minimum of 2 years of medical claims adjudication experience in a health plan or TPA environment.
• Experience with claims processing platforms such as Facets, QNXT, HealthEdge, or similar.
• Knowledge of CPT, ICD-10, HCPCS, revenue codes, and standard reimbursement methodologies.
• Understanding of COB rules, Medicare Secondary Payer regulations, and state insurance mandates.
• Strong analytical skills with consistent attention to detail while meeting production goals.

Responsibilities

• Adjudicate medical, surgical, and ancillary claims against plan benefits and contract terms.
• Apply correct reimbursement methodologies, including fee schedule, DRG, per diem, and percentage of charge.
• Identify and resolve coordination of benefits, subrogation, and third-party liability situations.
• Process claim adjustments, voids, and reprocessing requests within established turnaround standards.
• Research and resolve provider disputes, member appeals, and complex claim inquiries.
• Identify potential fraud, waste, and abuse patterns and refer them to special investigations.
• Maintain claims processing accuracy at or above the 97% quality benchmark.
• Stay current with CMS regulations, state mandates, and payer specific claims processing rules.
• Process out-of-network claims, including reasonable and customary determinations and member balance calculations.

Skills

Analytical thinking

Attention to detail

Time management

Remote work discipline

Education

High school diploma

Associate degree in healthcare or business

Tools

Facets

QNXT

HealthEdge

Job description

TalentLNX LLC is seeking a Health Plan Claims Examiner for a fully remote U.S. role. You will adjudicate medical, surgical, and ancillary claims, applying multiple reimbursement methods, while ensuring COB compliance and timely processing.

Ideal candidates have at least 2 years of claims adjudication experience, familiarity with Facets/QNXT/HealthEdge, and solid knowledge of CPT, ICD-10, HCPCS, and CMS rules. Remote, full-time, with standard business hours.