Claims Reviewer
Claims Reviewer Opportunity Join a dynamic team where your expertise in claims review can make a real difference! We're looking for a detail-oriented Claims Reviewer who can apply clinical and coding knowledge to ensure accurate claims processing. If you have a strong foundation in medical claims and are passionate about quality, we want to hear from you! Position Highlights
- Role: Conduct retrospective review of medical, surgical, and behavioral health claims.
- Focus: Evaluate claims for medical necessity, appropriateness, and adherence to program benefits.
- Collaboration: Work closely with medical directors, providers, peer reviewers, and various internal teams.
Key Responsibilities
- Review and validate claims using established criteria and processing guidelines.
- Prepare cases for payment or further review.
- Identify opportunities for process improvement and flag quality or fraud concerns.
- Support peers and clinical/non-clinical staff with claims and coding inquiries.
What You Bring
- Required:
- High School Diploma or GED.
- 2+ years of experience in medical claims review.
- Familiarity with medical claims processing and terminology.
- Preferred:
- Coding experience.
- Knowledge of behavioral health claims.
Skills for Success
- Strong technical skills in claims tools (e.g., CDST, Supercoder).
- Organizational and team-building abilities.
- Resilience in a fast-paced, high-intensity environment.
- Effective communication and problem-solving.
Additional Requirements
- Must pass background, credit, and drug screening.
- Adherence to federal THC policies (medical card required if applicable).
Eligible Locations The position is remote, but you can only reside in the following states: AK, AR, AZ, CO, DC, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NC, ND, NE, NM, NV, OK, OR, SC, SD, TN, TX, UT, VA, WA, WI, WY. Ready to bring your claims expertise to a rewarding role? Apply today to be part of our team! Apply Job!