Sr. Medical Claims Processor

Senior Medical Claims Processor - Job Description

The Senior Medical Claims Processor is responsible for reviewing, processing, and resolving medical insurance claims with a high level of accuracy and efficiency. This role requires a strong understanding of healthcare billing practices, coding systems, and payer guidelines to ensure timely reimbursement and compliance with industry regulations.

Key Responsibilities:

• Review, analyze, and process medical claims in accordance with insurance policies, contracts, and healthcare regulations
• Ensure accuracy of claim details, including patient information, coding (ICD-10, CPT, HCPCS), and billing data prior to submission
• Investigate and resolve denied, rejected, or pending claims by working with providers, payers, and internal departments
• Maintain compliance with HIPAA and all applicable federal, state, and payer-specific regulations
• Perform claims adjustments, corrections, and resubmissions as needed to ensure proper reimbursement
• Monitor claims processing workflows to meet productivity and quality standards
• Communicate effectively with insurance companies and healthcare providers to expedite claims resolution
• Maintain detailed documentation of claims activity, correspondence, and outcomes for audit and reporting purposes
• Identify trends in claim denials or errors and recommend process improvements to reduce rework and increase efficiency
• Provide guidance or support to junior claims processors and assist with training as needed

Qualifications:

• 3-5 years of experience in medical claims processing, medical billing, or revenue cycle management
• Strong knowledge of medical terminology, ICD-10, CPT, and HCPCS coding
• Familiarity with payer guidelines, EOBs, and claim adjudication processes
• Proficiency in claims processing systems and Microsoft Office (especially Excel)
• High attention to detail, accuracy, and problem-solving skills
• Ability to work in a fast-paced environment and manage high claim volumes
• Strong communication and organizational skills

Preferred:

• Experience with multiple insurance payers (commercial, Medicare, Medicaid)
• Knowledge of revenue cycle workflows and compliance standards

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.