Claims Reviewer

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! Apply tot his job Apply To this Job