- Hiring from
- United States
- Work type
- Remote
- Posted
- Oct 2, 2026
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*This is a Remote position.
Key Responsibilities
Required Qualifications
Key Responsibilities
- Apply medical policy, contractual provisions, and operational procedures to ensure accurate adjudication and/or adjustment of Group Health and Workers' Compensation Hospital and Medical claims.
- Resolve claim holds, review history records, and determine benefit eligibility for services rendered.
- Research and document all pertinent information on claims requiring adjudication.
- Respond to inquiries related to specific claim issues via email, chat, or verbal communication.
- Perform non-standard claim data entry, including detailed claim notation and documentation.
- Complete assigned projects and tasks within established deadlines.
- Assist Customer Service, Casualty, Medical Management, and Management teams by providing support in resolving claims and responding to questions and concerns.
- Meet or exceed production and quality standards established for the role.
- Escalate issues to the Manager or Supervisor when appropriate.
- Perform other related duties as assigned to support departmental goals.
Required Qualifications
- High School Diploma or GED required.
- 1 to 3 years of medical or hospital claims processing experience.
- Strong understanding of medical terminology, CPT/HCPCS and ICD coding, and benefits administration.
- Ability to interpret medical policies, provider contracts, and plan documents.
- Excellent analytical and problem-solving skills, with the ability to identify discrepancies and resolve complex claim issues.
- Proficiency with claims processing systems, data entry platforms, and standard office software (e.g., Microsoft Office).
- Strong written and verbal communication skills for interacting with internal teams and responding to inquiries.
- Ability to manage multiple tasks and meet performance standards for speed and accuracy.