Senior High Risk Claims Specialist

Job Summary

To ensure accurate and timely processing of high-stakes claims, the full-time Senior High Risk Claims Specialist will adjudicate complex healthcare claims, enforce compliance standards, and manage production targets while serving as a resource for the claims team.

Key responsibilities

• Adjudicate high-dollar and specialty claims from intake through resolution, ensuring accuracy and compliance
• Enforce quality standards by examining claims against company policies and regulatory requirements
• Guide the claims team through escalations and serve as a point of contact for clients and vendors

Required qualifications

• Degree in Business, Healthcare Administration, or a related field preferred; equivalent work experience considered
• 4+ years of experience in claims processing, adjudication, or related healthcare/insurance operations
• Thorough knowledge of medical terminology and coding (ICD-9, CPT, HCPCS)
• Proficiency with claims processing systems and Microsoft Office Suite
• Healthcare industry background preferred, including health insurance or clinical operations experience