Claims Reviewer

Claims Reviewer Opportunity

Join a dynamic team where your expertise in claims review can make a real difference! We’re looking for a detail-oriented Claims Reviewer who can apply clinical and coding knowledge to ensure accurate claims processing. If you have a strong foundation in medical claims and are passionate about quality, we want to hear from you!

Position Highlights
• Role: Conduct retrospective review of medical, surgical, and behavioral health claims.
• Focus: Evaluate claims for medical necessity, appropriateness, and adherence to program benefits.
• Collaboration: Work closely with medical directors, providers, peer reviewers, and various internal teams.

Key Responsibilities
• Review and validate claims using established criteria and processing guidelines.
• Prepare cases for payment or further review.
• Identify opportunities for process improvement and flag quality or fraud concerns.
• Support peers and clinical/non-clinical staff with claims and coding inquiries.

What You Bring
• Required:
• High School Diploma or GED.
• 2+ years of experience in medical claims review.
• Familiarity with medical claims processing and terminology.
• Preferred:
• Coding experience.
• Knowledge of behavioral health claims.

Skills for Success
• Strong technical skills in claims tools (e.g., CDST, Supercoder).
• Organizational and team-building abilities.
• Resilience in a fast-paced, high-intensity environment.
• Effective communication and problem-solving.

Additional Requirements
• Must pass background, credit, and drug screening.
• Adherence to federal THC policies (medical card required if applicable).

Eligible Locations
The position is remote, but you can only reside in the following states: AK, AR, AZ, CO, DC, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NC, ND, NE, NM, NV, OK, OR, SC, SD, TN, TX, UT, VA, WA, WI, WY.

Ready to bring your claims expertise to a rewarding role? Apply today to be part of our team!