Medicare Claims Processor
Core
Review and process Medicare insurance claims to determine payment, denial, or return outcomes based on CMS guidelines and benefit provisions.
Role type
Medicare Claims Processor
Builds
Accurate claim adjudication and payment determinations for a growing Medicare health plan
Domain
Healthcare / Medicare Claims Administration
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medicare claims processing, CMS guidelines interpretation, eligibility verification, claim history analysis, payment liability determination, data entry accuracy, HIPAA compliance, medical terminology, insurance processes, UB/institutional claims handling
Preferred skills
Bachelor's in medical coding, 3+ years Medicare claims experience, EPIC software proficiency, medical coding knowledge, Medicare supplement product knowledge
Technologies
EPIC, Microsoft Office, Microsoft Teams
Responsibilities
Review and process Medicare claims; Determine claim outcomes (pay/deny/return); Verify data entry accuracy; Analyze claims for insurance carrier liability; Resolve claim edits and determine eligibility; Review payment levels and supporting information; Interpret Medicare benefit provisions; Read and interpret explanations of benefits (EOBs); Maintain work queues per production standards; Escalate complex issues; Provide mentorship to team members; Maintain confidentiality of PHI
Seniority
Individual Contributor, operational level