Medicare Advantage Claims Processor

Job Summary

Specializing in cross-border claims processing, the part-time Healthcare Claims Processor will review and adjudicate complex medical claims remotely, ensuring compliance with localized Medicare Advantage guidelines.

Key Responsibilities

• Review, audit, and finalize complex medical claims routed via the electronic Inter-Plan Teleprocessing System (ITS)
• Validate and adjudicate out-of-state claims against the member's localized Medicare Advantage benefit rules and plan guidelines
• Troubleshoot and resolve specialized system pends and billing discrepancies to ensure seamless inter-plan provider reimbursement

Required Qualifications

• HS Diploma with 3+ years of healthcare claims processing experience
• Prior experience with the ITS Home workflow and BlueCard program parameters
• Experience processing Medicare Advantage claims or utilizing the Facets core claims platform (Facets G6 or Facets 360)
• Exceptional analytical skills for cross-referencing multi-layered plan benefits
• Strong productivity mindset for managing high-volume claims lines