Medicare Claims Processor

Job description

**This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Medicare Claims Processor based in the United States.** This role offers an opportunity to contribute to the operations of a growing Medicare health plan and help ensure accurate, timely claims decisions. You will review and process Medicare claims ranging from routine transactions to complex specialty claim research. Your work will involve applying CMS guidelines, benefit provisions, and organizational policies to determine appropriate claim outcomes. You will analyze eligibility, claim history, edits, payment levels, and insurance liability to support accurate adjudication. Working in a collaborative claims environment, you will interact with internal and external partners while helping resolve issues efficiently. Strong attention to detail, critical thinking, and knowledge of Medicare claims processes will be essential to maintaining quality and compliance. This is a full-time, remote opportunity suited to a detail-oriented professional who can work independently while maintaining high productivity and service standards. ### Accountabilities - Review, analyze, and process Medicare insurance claims in accordance with CMS guidelines, applicable benefits, contracts, and organizational policies. - Determine appropriate claim outcomes, including whether claims should be paid, denied, or returned for additional information or correction. - Verify the accuracy of data entry and maintain complete and accurate claim and member records. - Analyze claims to determine the extent of insurance carrier liability and establish appropriate payment responsibility. - Resolve claim edits, review member and claim history, and determine eligibility for specific services. - Review payment levels and supporting information to reach accurate final payment determinations. - Interpret Medicare benefit provisions and apply relevant claims-processing guidelines to individual cases. - Review paper and electronic claims, including online entries, corrections, quality controls, and final adjudication activities. - Read and interpret explanations of benefits (EOBs) and use relevant information to support claims decisions and member inquiries. - Maintain assigned work queues in accordance with departmental production, quality, and service standards. - Communicate effectively with internal and external colleagues to resolve claims-related questions and issues. - Escalate complex or unresolved issues to the appropriate level of supervision when necessary. - Participate in required training and demonstrate proficiency in new processes, systems, and procedures. - Provide guidance or mentorship to less experienced team members when requested by leadership. - Maintain strict confidentiality of patient and member information in accordance with PHI and HIPAA requirements. ## Requirements - Associate degree in a related healthcare field, or a high school diploma/equivalent combined with at least 3 years of healthcare claims billing and processing experience. - At least 1 year of Medicare claims processing experience. - At least 1 year of experience working with CMS requirements and professional and UB/institutional claims. - At least 1 year of customer service experience. - Bachelor’s degree in medical coding or a related healthcare field is preferred, or 4 years of equivalent industry experience. - Three years of Medicare claims processing experience is preferred. - Three or more years of medical or institutional claims processing and customer service experience is preferred. - Experience with Medicare medical insurance and Medicare supplement products is preferred. - Familiarity with EPIC software and electronic health record systems is preferred. - Working knowledge of administrative and clerical procedures, file management, record maintenance, and common office applications. - Ability to navigate multiple systems simultaneously and follow established procedures and guidelines. - Strong written and verbal communication, interpersonal, customer service, and telephone etiquette skills. - Ability to use mathematics and apply claims-processing calculations accurately. - Understanding of medical insurance payment requirements and basic knowledge of covered healthcare services. - Knowledge of medical terminology, third-party payors, insurance processes, Medicare terminology, procedure and diagnosis codes, and HIPAA requirements. - Strong attention to detail, organization, critical thinking, time management, and multitasking skills. - Ability to work independently, take direction, identify problems, and apply established methods to improve efficiency and customer satisfaction. - Ability to maintain a positive, collaborative, and professional approach when working with colleagues, leadership, and external partners. - Comfort working remotely and spending extended periods working at a computer with limited social interaction at times. ## Benefits - Full-time schedule of **40 hours per week**. - Remote work opportunity within the United States. - Opportunity to contribute to Medicare claims operations supporting healthcare access and accurate benefit administration. - Collaborative environment with opportunities to work across claims, customer service, and healthcare operations functions. - Professional training and development to build proficiency in claims processes, systems, and procedures. - Exposure to Medicare, CMS requirements, professional and institutional claims, and healthcare insurance operations. - Opportunity to provide mentorship and contribute to process and team improvements. - Standard remote office environment supported by technology and business applications such as Microsoft Office, Microsoft Teams, and EPIC.