Medicare Advantage Claims Specialist

Job Summary

Reviewing and processing Medicare Advantage medical claims, the full-time remote Claims Review Specialist will ensure accurate adjudication of claims requiring manual intervention, adhering to company policies and clinical guidelines.

Key responsibilities

• Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner
• Review and research assigned claims by navigating multiple systems to capture necessary data for processing
• Communicate and collaborate with external departments to resolve claims errors and issues effectively

Required qualifications

• High School Diploma or Equivalent required; Associate's Degree preferred
• 1-2 years of related healthcare experience required
• 2-3 years of previous experience in the health insurance industry, particularly in claims processing, highly preferred
• Experience with Medicare claims processing highly preferred
• Knowledge of medical billing, coding principles, and healthcare regulations, including HIPAA guidelines