Senior Healthcare Claims Processor (Onsite)
Global Health/Hospital Organization- Irving Texas $22-23hr
Position Summary
The Claims Examiner Senior is responsible for reviewing, analyzing, researching, and resolving complex medical claims in accordance with claims processing guidelines, policies, and federal regulations. This position plays a critical role in ensuring the accuracy, quality, and compliance of claims adjudication while collaborating with multiple operational departments to support efficient claims processing and payment integrity.
Key Responsibilities
- Review, analyze, and process complex medical claims in accordance with established policies, procedures, processing guidelines, and regulatory requirements.
- Adjudicate medical claims submitted on CMS-1500 and CMS-1450/UB-04 claim forms from facilities, physicians, home health agencies, durable medical equipment providers, laboratories, and other healthcare providers.
- Research and resolve claim discrepancies, payment issues, and processing exceptions.
- Manage claim projects related to overpayments, underpayments, manual processing errors, benefit updates, contract changes, and fee schedule modifications.
- Process provider refunds, reconsiderations, direct member reimbursements, and claim adjustments.
- Execute recovery activities for claim overpayments and support batch claim adjudication processes.
- Investigate and resolve moderately complex claims issues, escalating concerns when appropriate to leadership.
- Partner with Business Configuration, Network Management, Provider Data, Complaints, Appeals and Grievances, and other operational teams to ensure accurate claims processing and quality assurance.
- Participate in testing, validation, and implementation activities related to system upgrades, process enhancements, and operational improvements.
- Serve as a subject matter resource and provide guidance to team members on claims processing policies and procedures.
- Ensure compliance with federal regulations, organizational standards, and quality expectations.
Qualifications
- Experience processing and adjudicating medical claims in a healthcare, managed care, health insurance, or third-party administrator environment.
- Strong knowledge of CMS-1500 and CMS-1450/UB-04 claim forms.
- Understanding of medical terminology, provider billing practices, reimbursement methodologies, and claims processing guidelines.
- Experience handling claim adjustments, overpayment recovery, provider refunds, and reimbursement requests.
- Strong analytical, problem-solving, and research skills.
- Ability to manage multiple priorities while maintaining accuracy and attention to detail.
- Proficiency with claims processing systems and Microsoft Office applications.
- Excellent communication and collaboration skills.
Why Join Us?
Join a mission-driven global health organization dedicated to improving healthcare outcomes through operational excellence, compliance, and exceptional service. This role offers the opportunity to work with experienced professionals while contributing to meaningful healthcare initiatives that impact members and providers worldwide