Claim Processor III

Medica•,

7d•$37,600 - $56,385•Remote

About The Position

Medica's Claims Processor III is responsible for the accurate and timely adjudication of complex commercial and Individual & Family Business (IFB) medical claims from receipt through final resolution. This role requires advanced knowledge of claims processing, benefit administration, coordination of benefits, medical billing and coding, and healthcare industry regulations. The Claims Processor III works independently to analyze claims, apply standard operating procedures (SOPs), resolve processing issues, and collaborate with internal and external partners to ensure accurate claim outcomes. Performs other duties as assigned.

Requirements

High school diploma or equivalent
Minimum of 3 years of medical claims processing experience

Nice To Haves

Advanced knowledge of healthcare claims adjudication processes
Experience using HealthRules and/or WebTPA
Experience processing commercial and Individual & Family Business (IFB) claims
Familiarity with provider pricing methodologies and network arrangements
Understanding of: Coordination of Benefits (COB)
Medical billing and coding concepts
Benefit administration
Coinsurance, copays, member liability, and balance billing
Commercial health insurance claims processing
Ability to interpret and follow detailed standard operating procedures
Strong analytical, critical thinking, and problem-solving skills
Proficiency with Microsoft Excel and Microsoft Word
Experience working with claim vendors, pricing systems, and external portals
Knowledge of healthcare operations and claims workflows

Responsibilities

Adjudicate professional and institutional medical claims from initial receipt through final determination
Process an average of 35 to 50 claims daily while maintaining quality and productivity standards
Review claims for coding accuracy, pricing, benefit application, eligibility, and payment determination
Analyze complex claim scenarios involving coordination of benefits, member liability, coinsurance, copays, and balance billing
Identify and resolve claim discrepancies, system issues, and payment irregularities
Interpret and apply benefit plans, policies, regulatory requirements, and internal procedures
Navigate complex claims involving high-dollar amounts, multiple service dates, specialized provider arrangements, and unique benefit situations
Utilize critical thinking and sound judgment to determine appropriate claim outcomes
Escalate issues requiring additional review, coding validation, or medical review
Work closely with coders, medical review teams, auditors, analysts, account managers, and operational partners
Coordinate claim research and issue resolution with internal stakeholders
Support escalated member, provider, and client issues requiring specialized claims expertise
Share knowledge and best practices with team members
Process claims within HealthRules and pricing of claims for WebTPA platforms
Access and utilize external pricing and vendor portals as needed
Work with network partners and vendors to obtain pricing and claim adjudication information
Follow established SOPs and workflow documentation to ensure processing consistency
Meet accuracy, turnaround time, and productivity expectations
Identify trends and opportunities to improve processes and workflows
Maintain compliance with departmental policies and regulatory requirements
Contribute to team goals and continuous improvement initiatives