Senior High Risk Claims Specialist

Job Summary

To ensure accurate and compliant outcomes for high-stakes claims, the full-time Senior High Risk Claims Specialist will adjudicate complex healthcare, dialysis, and stop loss claims while guiding the claims team and maintaining production targets in a remote setting.

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, providing expertise on complex questions and edge cases

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
• 4+ years of experience with multiple claims processing systems
• Thorough knowledge of medical terminology and coding (ICD-9, CPT, HCPCS)
• Healthcare industry background preferred, including health insurance or clinical operations experience