We are seeking an experienced Medical Claims professional to join a benefits organization as a Remote Provider Reimbursement and Claims Specialist. 

Are you ready for your next career adventure as a Remote Provider Reimbursement and Claims Specialist? We are currently hiring immediately! We are dedicated and devoted to consistently improving the culture of our team, and focus on finding the “right people '' - Not just the right resume! 

What we provide to you as a full-time teammate: 

We offer a competitive benefits package that is on par with most of the leading healthcare organizations. Apply today if you are interested in getting your name in the mix!

Remote Provider Reimbursement and Claims Specialist Overview:

The Provider Reimbursement and Claims Specialist is a subject matter expert responsible for reviewing, auditing, and pricing a claim.  This role is responsible for the review, processing, and accurate pricing of all claim types. This role requires strong attention to detail, adherence to established policies, and the ability to interpret provider documents to ensure accurate and timely claim payments.

Remote Provider Reimbursement and Claims Specialist Day to Day:

• Manual Review & Pricing: Conduct detailed, manual review and pricing of claims (e.g., out-of-network or non-standard claims) using provider contracts, pricing methodologies, and regulatory mandates where standard auto-adjudication fails.
• Contract Interpretation: Interpret hospital, medical group and provider contracts with depth to accurately determine payment methodologies, fee schedules, and reimbursement rates for complex claims.
• Process & Inventory Management: Keep the department's claim pend queue inventory current, clearing edit queues by processing claims according to regulatory requirements and plan benefits.
• Coding & Necessity Review: Review claims thoroughly for correct CPT/HCPCS, ICD-10 coding, necessity, limitations, and exclusions based on claims policies.
• Error Resolution: Independently investigate and resolve complex claim edits and making informed decisions regarding clearing edits and claim payment.
• Independent Work: Work independently to resolve difficult or complex transactions, managing smaller claims-related projects from start to finish without continuous supervision.
• SME & Process Improvement: Act as a Subject Matter Expert (SME) for claims, actively identifying system problems, performing User Acceptance Tests (UAT) of new and existing provider contracts, and collaborating with management to enhance claims operations.

Remote Provider Reimbursement and Claims Specialist Job Type: W2 Contract until April 30 with potential for extension to June.

Remote Provider Reimbursement and Claims Specialist Schedule: 

Monday - Friday standard business hours (40 hours) within candidate’s time zone

Remote Provider Reimbursement and Claims Specialist Pay & Benefits: 

• $20.80/hr 
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Remote Provider Reimbursement and Claims Specialist Requirements:

• MUST know how to look up CMS guidelines for pricing
• Ideal candidates: have 2-3 claims pricing exp or billing exp, know CPT codes, how to look up CMS pricing tables, and understand flow of pricing a claim. 
• Demonstrated experience in manually reviewing and pricing claims, including interpreting provider contracts and fee schedules for non-standard payment methodologies.
• Hands-on working knowledge and background using claims processing systems
• Experience in medical claims procedures, governing rules, and all aspects of pricing and adjudication.
• Knowledge of CPT/HCPCS, ICD-10 claims coding, and medical terminology.

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients