Medical Claims Specialist

Medical Claims SpecialistCommunity Medical Group is seeking a detail-oriented, analytical, and results-driven Medical Claims Specialist to join our team.As a Contestation Specialist, you will play a critical role in identifying and recovering revenue opportunities by reviewing medical and pharmacy claims, eligibility data, and supporting documentation. This position works closely with Health Plans, Network & Contracting teams, and internal stakeholders to manage contestation activities, monitor recoveries, analyze trends, and ensure compliance with contractual and regulatory requirements. This is an excellent opportunity for a healthcare analytics professional who enjoys problem-solving, financial analysis, and driving measurable outcomes.Eligible employees receive a comprehensive benefits package that includes:17 days of paid time off11 paid holidays and one floating holidayMedical, dental, and vision coverage through UnitedHealthcare401(k) retirement plan with company matchCompany-paid life insuranceOpportunities for professional growthKey ResponsibilitiesReview medical and pharmacy claims, eligibility files, and clinical documentation to identify contestation opportunitiesDevelop, maintain, and improve contestation policies and proceduresMonitor and track contestable claims on a weekly and monthly basisEstablish and maintain strong working relationships with Health Plans and payer representativesSubmit contestation requests and supporting documentation within established filing deadlines and contractual requirementsCollaborate with the Network & Contracting team to evaluate claims trends and recommend process improvementsReport on open contestation cases, recoveries, aging reports, trends, and financial impactCreate and maintain tracking tools, dashboards, and reporting mechanisms to monitor contestation performanceAnalyze complex healthcare claims, pharmacy, eligibility, utilization, and reimbursement dataIdentify trends and provide recommendations based on data analysis and findingsMaintain organized records of contestation submissions, supporting evidence, correspondence, and payment outcomesEnsure compliance with Health Plan requirements, contractual obligations, regulatory guidelines, and internal policiesSupport revenue recovery initiatives and process improvement effortsPerform additional duties as assignedQualificationsBachelor's degree in Business, Finance, Computer Science, Engineering, Economics, or a related field preferred3-5 years of experience in healthcare claims analytics, payer operations, revenue recovery, or related healthcare functions requiredExperience working with health plans, provider organizations, or value-based care environments preferredKnowledge of healthcare reimbursement methodologies including DRGs, Revenue Codes, CPT Codes, HCPCS Codes, and bundled paymentsStrong understanding of healthcare claims processing, eligibility, and reimbursement cyclesKnowledge of institutional and professional billing and various sites of careAdvanced proficiency in Microsoft Excel requiredExperience with Power BI, Tableau, and/or Microsoft SQL preferredCertified Subrogation Recovery Professional (CSRP) certification preferredStrong analytical, financial, and problem-solving skillsExceptional attention to detail and accuracyExcellent written and verbal communication abilitiesAbility to manage multiple priorities in a fast-paced environmentStrong project management and organizational skillsAbility to work independently while collaborating effectively across departmentsBilingual English and Spanish preferredJoin a team dedicated to improving healthcare outcomes through operational excellence and financial stewardship. At Community Medical Group, you'll have the opportunity to make a meaningful impact by helping maximize revenue recovery, strengthen payer relationships, and support the continued delivery of high-quality care to the communities we serve.