Medical Claims Specialist

Medical Claims Specialist

Community 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 off
• 11 paid holidays and one floating holiday
• Medical, dental, and vision coverage through UnitedHealthcare
• 401(k) retirement plan with company match
• Company-paid life insurance
• Opportunities for professional growth

Key Responsibilities

• Review medical and pharmacy claims, eligibility files, and clinical documentation to identify contestation opportunities
• Develop, maintain, and improve contestation policies and procedures
• Monitor and track contestable claims on a weekly and monthly basis
• Establish and maintain strong working relationships with Health Plans and payer representatives
• Submit contestation requests and supporting documentation within established filing deadlines and contractual requirements
• Collaborate with the Network & Contracting team to evaluate claims trends and recommend process improvements
• Report on open contestation cases, recoveries, aging reports, trends, and financial impact
• Create and maintain tracking tools, dashboards, and reporting mechanisms to monitor contestation performance
• Analyze complex healthcare claims, pharmacy, eligibility, utilization, and reimbursement data
• Identify trends and provide recommendations based on data analysis and findings
• Maintain organized records of contestation submissions, supporting evidence, correspondence, and payment outcomes
• Ensure compliance with Health Plan requirements, contractual obligations, regulatory guidelines, and internal policies
• Support revenue recovery initiatives and process improvement efforts
• Perform additional duties as assigned

Qualifications

• Bachelor's degree in Business, Finance, Computer Science, Engineering, Economics, or a related field preferred
• 3-5 years of experience in healthcare claims analytics, payer operations, revenue recovery, or related healthcare functions required
• Experience working with health plans, provider organizations, or value-based care environments preferred
• Knowledge of healthcare reimbursement methodologies including DRGs, Revenue Codes, CPT Codes, HCPCS Codes, and bundled payments
• Strong understanding of healthcare claims processing, eligibility, and reimbursement cycles
• Knowledge of institutional and professional billing and various sites of care
• Advanced proficiency in Microsoft Excel required
• Experience with Power BI, Tableau, and/or Microsoft SQL preferred
• Certified Subrogation Recovery Professional (CSRP) certification preferred
• Strong analytical, financial, and problem-solving skills
• Exceptional attention to detail and accuracy
• Excellent written and verbal communication abilities
• Ability to manage multiple priorities in a fast-paced environment
• Strong project management and organizational skills
• Ability to work independently while collaborating effectively across departments
• Bilingual English and Spanish preferred

Join 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.