Senior Medical Claims Processor (Hybrid)

Senior Medical Claims Processor (Hybrid) Healthcare shouldn’t be something you worry about when taking care of your family. That’s why when you join Redirect Health, your healthcare costs nothing out of your paycheck—and the same is true for your spouse and children. No monthly premiums No surprise medical bills Most team members avoid tens of thousands of dollars in healthcare costs compared to traditional health plans. This isn’t a perk. It’s part of our mission. Redirect Health exists to make healthcare affordable for small businesses and people who can’t afford traditional employer insurance. We help real people navigate a system that is often confusing, expensive, and frustrating—and we do it with empathy, accountability, and simplicity. If you want your work to matter to families every single day, you’ll find purpose here. How We Work (Our Core Values in Action) At Redirect Health, our values guide how we show up for each other, our clients, and our members. We do our best work when we: Obsess Over People – We are always helpful, friendly, and human Own It to Completion – If we take something on, we see it through Always Improve & Adapt – We learn quickly and adjust without ego Start with “Yes, We Can Help You” – We lead with solutions Succeed as a Team – We win through trust and collaboration Detest Waste & Unnecessary Complexity – We simplify to focus on what matters About This Role The Senior Medical Claims Processor is responsible for accurately reviewing, processing, and adjudicating complex medical claims in accordance with company policies, client guidelines, and regulatory requirements. This role serves as a subject matter expert, supports junior staff, and ensures timely, compliant, and high-quality claims resolution. The position also plays a key role in operational workflow oversight, provider relations, escalations, auditing, and team development. Key Responsibilities: Claims Processing & Adjudication: Review and process medical claims with a high degree of accuracy and efficiency Handle manual claims and complex reprocessing (routine and advanced) Analyze complex claims, identify discrepancies, and determine appropriate adjudication Interpret and apply benefit plans, coding standards (CPT, ICD-10, HCPCS), and payer guidelines Process Coordination of Benefits (COBs) and non-coordinated claims Review and process appeals, accident letters, and medical records requests Generate and review EOB/EOP and no-pay letters Manage claim settlements and follow up on single case agreements and special arrangements Research & Issue Resolution: Investigate and resolve claim issues including eligibility, authorization, and billing discrepancies Handle escalations from internal teams, clients, and members Respond to provider and member inquiries (claim status, contact requests, etc.) Coordinate with care logistics and other departments to resolve complex issues Provider Relations: Communicate with providers regarding claims, payments, and issue resolution Negotiate payment discrepancies and rejections (lead responsibility) Maintain and strengthen provider relationships through ongoing communication Payment & Check Management: Review and manage check status, voids, reissues, and returned checks Handle recoupment letters and payment adjustments Support check printing and mailroom processes Respond to provider inquiries related to payment status Operational Oversight: Oversee daily workflow to ensure timely and accurate claims processing Submit physical claims to the clearinghouse Monitor group termination dashboard and pending premium payments Track and manage pend statuses (e.g., MOOP limits, visit limits, shareable limits) Maintain newborn eligibility tracking and non-coordinated lists Auditing & Reporting: Conduct weekly and bi-weekly claims audits Perform zero report updates and quality audits Ensure compliance with internal policies, client guidelines, and regulatory requirements (e.g., HIPAA) Maintain detailed documentation of claim decisions and actions taken Leadership & Team Support: Serve as the first point of contact for team support, questions, and issue resolution Act as an escalation point for complex or high-value claims Mentor and support junior claims processors; provide training and guidance Conduct initial performance coaching and development discussions Lead or provide backup support for daily team huddles Participate in quality assurance reviews and process improvement initiatives Qualifications: High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred 3–5+ years of medical claims processing experience Strong knowledge of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance concepts Experience with EHR/claims processing systems and payer platforms Familiarity with Medicare, Medicaid, and commercial insurance guidelines Experience handling complex claims, appeals, and provider negotiations Leadership or mentoring experience preferred Strong analytical and problem-solving skills High attention to detail and accuracy Ability to interpret complex policies and documentation Excellent time management and organizational skills Effective written and verbal communication Ability to work independently and manage high-volume workloads Leadership and mentoring capabilities Preferred Qualifications: CPC, CCS, or other relevant certification Experience in auditing or quality assurance Prior experience in a senior or lead claims role Hybrid work environment Extended screen time required Why Join Redirect Health What “Free Healthcare” Actually Means When we say free, we mean no money out of your paycheck and no cost when you need care: No monthly premiums No cost to add your spouse or children No deductibles (we reimburse them) No out-of-pocket maximums This benefit alone can save families tens of thousands of dollars. What You’ll Earn Salary range: $50,000 - $55,000 FREE healthcare for you and your entire family Paid time off & sick time 401(k) access A mission-driven team that believes in doing the right thing Legal Stuff Redirect Health is an Equal Opportunity Employer (EOE). Employment with Redirect Health is at-will. Nothing in this job posting or the application process creates a contract or guarantee of employment. Please note this job description is not designed to contain a comprehensive listing of activities, duties, or responsibilities required for this role. Duties, responsibilities, and activities may change at any time with or without notice. Redirect Health does not provide employment-based visa sponsorship now or in the future for this position. Applicants must be currently authorized to work in the United States without sponsorship. #J-18808-Ljbffr Redirect Health