Claims Adjudicator

Position Summary

Advanced MSO is seeking a detail-oriented and analytical Claims Adjudicator to join our growing Claims Operations team. The Claims Adjudicator is responsible for reviewing, evaluating, and processing medical claims to ensure they are adjudicated accurately, efficiently, and in accordance with payer contracts, company policies, and applicable healthcare regulations.

The ideal candidate has a strong understanding of medical claims processing, insurance guidelines, reimbursement methodologies, and medical terminology. This individual will play a critical role in maintaining operational excellence, supporting providers, and ensuring timely claim resolution while delivering outstanding service to our clients.

Key ResponsibilitiesClaims Review & Processing

• Review medical claims, supporting documentation, and medical records for completeness and accuracy.
• Evaluate claims according to payer contracts, benefit plans, fee schedules, and company policies.
• Process claims in a timely manner while maintaining a high level of accuracy.
• Identify discrepancies, missing documentation, or billing errors requiring further review.
• Maintain productivity and quality standards established by the department.

Claims Adjudication

• Approve, deny, pend, or adjust claims based on established guidelines and reimbursement policies.
• Calculate reimbursement amounts using contractual fee schedules and applicable payment methodologies.
• Apply medical necessity guidelines and payer-specific reimbursement rules.
• Document adjudication decisions clearly and accurately within the claims management system.

Compliance & Quality Assurance

• Ensure compliance with HIPAA, CMS regulations, Medicare, Medicaid, commercial payer requirements, and company policies.
• Maintain confidentiality of protected health information (PHI).
• Participate in quality assurance audits and implement corrective actions when necessary.
• Stay informed on regulatory updates and payer policy changes.

Investigation & Resolution

• Research claim discrepancies and resolve processing issues.
• Request additional documentation when necessary to complete claim reviews.
• Identify potential duplicate claims, billing inconsistencies, and possible fraudulent activity.
• Escalate complex claims to senior staff or management as appropriate.

Communication & Collaboration

• Communicate professionally with providers, health plans, internal departments, and other stakeholders regarding claim status and resolution.
• Collaborate with Customer Service, Provider Relations, Referral Coordination, and Claims Management teams to resolve claim issues.
• Assist with special projects and departmental initiatives aimed at improving operational efficiency.

QualificationsEducation

• High School Diploma or GED required.
• Associate or Bachelor's degree in Healthcare Administration, Business Administration, Finance, or a related field preferred.

Experience

• 1–3 years of experience in healthcare claims processing, medical billing, insurance, or claims adjudication preferred.
• Experience with Medicare Advantage, Managed Care Organizations (MCOs), IPA/MSO environments, or commercial health plans is highly desirable.

Technical Knowledge

• Knowledge of medical terminology, insurance benefits, and healthcare reimbursement methodologies.
• Familiarity with ICD-10, CPT, HCPCS coding, and medical billing practices.
• Experience using claims adjudication systems and Electronic Medical Record (EMR/EHR) platforms.
• Proficiency with Microsoft Office Suite, particularly Excel, Outlook, and Word.
• Strong data entry and computer navigation skills.

Skills & Competencies

• Excellent analytical and critical-thinking abilities.
• Strong attention to detail with exceptional accuracy.
• Effective problem-solving and decision-making skills.
• Excellent organizational and time management skills.
• Ability to prioritize workload and meet deadlines in a fast-paced environment.
• Professional written and verbal communication skills.
• Ability to work independently while collaborating effectively within a team.
• High level of integrity and commitment to confidentiality.

Compensation & Benefits

Salary: $19.00 – $25.00 per hour, based on experience and qualifications.

Advanced MSO offers a competitive compensation package and opportunities for professional growth within a collaborative healthcare organization committed to operational excellence and exceptional client service.

Benefits may include:

• Competitive hourly pay
• Paid Time Off (PTO)
• Paid Holidays
• Opportunities for professional development and career advancement
• Supportive and collaborative team environment

Why Join Advanced MSO?

At Advanced MSO, we are committed to delivering accurate, efficient, and compliant healthcare administrative solutions that support providers, health plans, and the patients they serve. Our Claims Adjudicators are essential to maintaining the integrity of our claims process while ensuring timely and accurate reimbursement.

If you enjoy problem-solving, working with data, and making a meaningful impact within healthcare operations, we invite you to become part of our growing team.

Pay: $19.00 - $25.00 per hour

Work Location: Hybrid remote in El Centro, CA 92243

Salary : $19 - $25