Senior Medical Claims Processor (Hybrid)

Senior Medical Claims Processor

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:

• 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
• 35+ 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

Skills & Competencies:

• 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

Work Environment:

• Hybrid work environment
• High-volume, fast-paced, deadline-driven setting
• Extended screen time required