Job Description

We are looking for a skilled and detail-focused Medical Claims Reviewer to perform comprehensive reviews of medical, surgical, and behavioral health claims for inpatient and outpatient services. This role involves using your clinical expertise, coding proficiency, and claims processing knowledge to assess and approve claims accurately and efficiently. You will ensure claims are aligned with program benefits and assist various stakeholders by providing coding-related insights and resolving inquiries related to claims processes.

Primary Responsibilities

• Review and evaluate medical, surgical, and behavioral health claims retrospectively for both inpatient and outpatient care.
• Utilize clinical knowledge and coding standards to validate claims and ensure accurate processing.
• Gather and prepare the necessary documentation for case payments and approvals.
• Verify adherence to program guidelines, benefits, and authorizations.
• Collaborate with medical directors, peer reviewers, Claims Administration, and other departments to share relevant clinical and coding information.
• Act as a resource for staff on coding and claims-related questions.

Qualifications

• High School Diploma or GED (Required).
• At least 2 years of experience reviewing medical claims.
• Comprehensive understanding of medical and institutional claims workflows.
• Strong grasp of medical coding practices and claims evaluation processes.
• High attention to detail with strong analytical and critical-thinking skills.
• Effective communication skills and the ability to work across teams.
• Proficiency in claims review software and related tools.

Benefits

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Job Tags

Flexible hours,

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