We are seeking a detail-oriented and experienced Medical Claims Examiner to join our team. The ideal candidate will have a strong understanding of medical claims processing, adjudication, and relevant regulations. This remote position offers the opportunity to contribute to a leading healthcare organization and make a direct impact on our members' access to care.

• Must reside within a 2.5-hour driving radius of our Denver location (Aurora, CO) due to occasional on-site meetings or training. (2500 S. Havana St. Arapahoe Aurora, CO 80202)
• Schedule : Mon-Fri 8am-4:30pm MST *one fully trained, flex schedule-can start as early as 6am or as late as 10am MST.

Daily Job Duties:

• Adjudicate medical claims/bills for payment or denial within contract agreements, guidelines, and protocols, utilizing knowledge of medical claim/bill payment processing and medical regulations.
• Ensure claims/bills meet eligibility, benefit, and Medicare requirements.
• Research claims/bills for appropriate supporting documents and documentation.
• Analyze and adjust data and benefits criteria for payment.
• Respond to and research vendor and member problems, questions, and complaints.
• Utilize knowledge of organizational policies and procedures to ensure adherence to contractual agreements and non-contracted pricing arrangements, along with compliance with government regulations.

Requirements:

• Minimum 3 years of claims processing adjudication experience (payment determination to process the claim to a clean or denied status, not simply billing, claim submission, or insurance verification).
• Knowledge of medical terminology and International Classification of Diseases (ICD-10) and Current Procedure Terminology (CPT) coding.
• Demonstrated skills in analysis, interpretation, and application of procedures, practices, and methods used in claims adjudication without direct supervision.
• Basic PC skills.
• Working knowledge of Microsoft Word.
• Must reside within a 2.5-hour driving radius of our Denver location (Aurora, CO) due to occasional on-site meetings or training.