Claims Reviewer

Job Description

Job Description

Claims Reviewer Opportunity

Join a dynamic team where your expertise in claims review can make a real difference! We're looking for a detail-oriented Claims Reviewer who can apply clinical and coding knowledge to ensure accurate claims processing. If you have a strong foundation in medical claims and are passionate about quality, we want to hear from you!

Position Highlights

Role : Conduct retrospective review of medical, surgical, and behavioral health claims.

Focus : Evaluate claims for medical necessity, appropriateness, and adherence to program benefits.

Collaboration : Work closely with medical directors, providers, peer reviewers, and various internal teams.

Key Responsibilities

Review and validate claims using established criteria and processing guidelines.

Prepare cases for payment or further review.

Identify opportunities for process improvement and flag quality or fraud concerns.

Support peers and clinical / non-clinical staff with claims and coding inquiries.

What You Bring

Required :

High School Diploma or GED.

2+ years of experience in medical claims review.

Familiarity with medical claims processing and terminology.

Preferred : Coding experience.

Knowledge of behavioral health claims.

Skills for Success

Strong technical skills in claims tools (e.g., CDST, Supercoder).

Organizational and team-building abilities.

Resilience in a fast-paced, high-intensity environment.

Effective communication and problem-solving.

Additional Requirements

Must pass background, credit, and drug screening.

Adherence to federal THC policies (medical card required if applicable).

Eligible Locations

The position is remote, but you can only reside in the following states : AK, AR, AZ, CO, DC, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NC, ND, NE, NM, NV, OK, OR, SC, SD, TN, TX, UT, VA, WA, WI, WY.

Ready to bring your claims expertise to a rewarding role? Apply today to be part of our team!