Senior Claims Researcher with Coding Certification

Job Summary

As a key individual contributor, the remote Senior Claims Researcher with Coding Certification will execute high-level technical audits and testing to ensure accurate claims payment, focusing on deep-dive research and quality audits within the adjudication ecosystem.

Key responsibilities

• Execute the monthly audit plan by performing detailed reviews of claims to ensure alignment with provider contracts and pricing guidelines
• Conduct deep-dive research into payment variances to identify root causes related to configuration logic and policy interpretation
• Compile and present audit findings that highlight trends and enterprise risk areas for executive-level reporting

Required qualifications

• 5+ years of experience in Medicare Advantage claims auditing, research, or complex adjudication
• Current coding certification (CPC, CCS, COC, or CIC) is required
• Deep technical proficiency in HealthEdge HRP and Source
• Strong familiarity with AI tools and a desire to leverage technology for auditing processes
• Ability to translate complex technical findings into clear, actionable reports for leadership