Medical Billing Processor

Lyric National • Lincolnwood, IL

7d

About The Position

The Claims Adjuster investigates, evaluates, and resolves complex, high-dollar, or disputed health insurance claims. This role conducts detailed reviews of medical documentation, benefits coverage, and contractual terms to determine liability and negotiate equitable resolutions while maintaining regulatory compliance and protecting plan integrity.

Requirements

• Associate's or Bachelor's degree preferred; equivalent experience considered.
• 3+ years in health insurance claims, with emphasis on complex adjudication, appeals, or investigations.
• Medicaid/Medicare claims experience
• Strong knowledge of ICD-10, CPT/HCPCS, DRGs, NCCI edits, medical necessity policies, CMS/state rules, ERISA (as applicable).

Nice To Haves

• Proficiency with claims platforms (e.g., Facets, QNXT, Epic Tapestry), EDI (837/835), medical record review tools, and MS Office. Microsoft Dynamic Preferred.
• Experience in provider contract interpretation, SIU/FWA, or utilization management.

Responsibilities

• Complex Case Investigations: Handle escalated claims involving multi-layer benefits, COB, subrogation, prior authorization disputes, and medical necessity.
• Evidence Review: Analyze medical records, clinical notes, coding, authorization history, and provider contracts to determine claim outcomes.
• Determinations & Negotiations: Make coverage and payment decisions; negotiate settlements with providers; recommend denials or adjustments with clear rationale.
• Fraud/Waste/Abuse (FWA): Identify potential FWA indicators; coordinate with SIU for further review; document findings.
• Appeals & Grievances: Prepare case files, decision letters, and summaries for internal and external appeals; represent the organization in hearings when needed.
• Stakeholder Collaboration: Work closely with medical management, UM, provider relations, legal/compliance, and finance on complex cases.
• Policy & Compliance: Ensure adherence to HIPAA, CMS, state regulations, ERISA (as applicable), and internal policies.
• Training & Mentorship: Provide guidance to Claims Processors; contribute to SOP updates and best practices.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree