Claim Processor III

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

Medica's Claims Processor III is responsible for the accurate and timely adjudication of complex commercial and Individual & Family Business (IFB) medical claims from receipt through final resolution. This role requires advanced knowledge of claims processing, benefit administration, coordination of benefits, medical billing and coding, and healthcare industry regulations. The Claims Processor III works independently to analyze claims, apply standard operating procedures (SOPs), resolve processing issues, and collaborate with internal and external partners to ensure accurate claim outcomes. Performs other duties as assigned.

Key Responsibilities

Process Complex Medical Claims

• Adjudicate professional and institutional medical claims from initial receipt through final determination
• Process an average of 35 to 50 claims daily while maintaining quality and productivity standards
• Review claims for coding accuracy, pricing, benefit application, eligibility, and payment determination
• Analyze complex claim scenarios involving coordination of benefits, member liability, coinsurance, copays, and balance billing
• Identify and resolve claim discrepancies, system issues, and payment irregularities

Apply Advanced Claims Knowledge

• Interpret and apply benefit plans, policies, regulatory requirements, and internal procedures
• Navigate complex claims involving high-dollar amounts, multiple service dates, specialized provider arrangements, and unique benefit situations
• Utilize critical thinking and sound judgment to determine appropriate claim outcomes
• Escalate issues requiring additional review, coding validation, or medical review

Collaborate Across Functions

• Work closely with coders, medical review teams, auditors, analysts, account managers, and operational partners
• Coordinate claim research and issue resolution with internal stakeholders
• Support escalated member, provider, and client issues requiring specialized claims expertise
• Share knowledge and best practices with team members

Utilize Claims Systems and Vendor Resources

• Process claims within HealthRules and pricing of claims for WebTPA platforms
• Access and utilize external pricing and vendor portals as needed
• Work with network partners and vendors to obtain pricing and claim adjudication information
• Follow established SOPs and workflow documentation to ensure processing consistency

Support Operational Excellence

• Meet accuracy, turnaround time, and productivity expectations
• Identify trends and opportunities to improve processes and workflows
• Maintain compliance with departmental policies and regulatory requirements
• Contribute to team goals and continuous improvement initiatives

Required Qualifications

• High school diploma or equivalent
• Minimum of 3 years of medical claims processing experience

Preferred Qualifications

• Advanced knowledge of healthcare claims adjudication processes
• Experience using HealthRules and/or WebTPA
• Experience processing commercial and Individual & Family Business (IFB) claims
• Familiarity with provider pricing methodologies and network arrangements
• Understanding of:
• Coordination of Benefits (COB)
• Medical billing and coding concepts
• Benefit administration
• Coinsurance, copays, member liability, and balance billing
• Commercial health insurance claims processing
• Ability to interpret and follow detailed standard operating procedures
• Strong analytical, critical thinking, and problem-solving skills
• Proficiency with Microsoft Excel and Microsoft Word
• Experience working with claim vendors, pricing systems, and external portals
• Knowledge of healthcare operations and claims workflows

This position is a Remote role. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI

The full salary grade for this position is $37,600 - $64,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $37,600 - $56,385. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data.  In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.