Claims Clerk I

The Temporary UM Claims Examiner supports Utilization Management and Claims Operations by reviewing claims requiring UM intervention, validating authorization requirements, identifying continuity of care protections, researching claim discrepancies, and ensuring accurate routing and adjudication of claims. This role performs administrative and analytical review activities and escalates clinical determinations to licensed UM staff when appropriate.

Job Title: Claims Clerk I
Schedule: Local Time
Location: 100% Remote
Duration: 03+ Months

Position Summary:
The Temporary UM Claims Examiner supports Utilization Management and Claims Operations by reviewing claims requiring UM intervention, validating authorization requirements, identifying continuity of care protections, researching claim discrepancies, and ensuring accurate routing and adjudication of claims. This role performs administrative and analytical review activities and escalates clinical determinations to licensed UM staff when appropriate.

Essential Responsibilities:
Review claims requiring authorization validation or UM review.
Compare billed services against approved authorizations.
Research claim history, provider documentation, and authorization records.
Identify Continuity of Care (COC) claims and validate supporting documentation.
Resolve UM-related claims edits and discrepancies.
Route claims to the appropriate payment, non-payment, or UM review queue.
Document findings clearly and maintain audit-ready records.
Ensure compliance with state, federal, and turnaround time requirements.
Support backlog reduction and special projects during implementation or transition periods.
Escalate unclear, conflicting, or clinically complex cases to licensed UM staff.