Claims Processor

Job Summary

Reviewing and determining resolutions for MVH appealable denials, the full-time remote Appeals Claims Processor will process medical and factual appeals, verify claims information, and collaborate with the Nursing team on medical decision-making.

Key responsibilities

• Process appeals received from providers, beneficiaries, and DHA, ensuring compliance with MVH regulations
• Translate, research, and verify claims information to confirm all requirements are met
• Complete CNOTE, create Summary Logs, calculate disputed amounts, and send determination letters

Required qualifications

• U.S. citizenship is required due to Department of Defense restrictions
• High School Diploma or GED or equivalent experience
• 1 or more years of experience in a claims processing role
• Knowledge of TRICARE Policy Manuals, claims adjudication procedures, and MVH system programs
• Ability to effectively utilize resources for research and verification of claims