Medical Claims Processor

Job Title: Claims & Benefits Resolution Specialist

Location: West Valley City, UT

Department: Revenue Cycle Management – Central Business Office

Assignment Length: 3 Months (Potential Extension)

Position Summary: This role performs comprehensive audits and resolution activities across the claims lifecycle, ensuring accurate billing, timely reimbursement, and compliance with payer requirements. The specialist will handle complex claim discrepancies, conduct follow-up with payers, and coordinate with clinical and non-clinical teams to finalize claim determinations. The ideal candidate has strong revenue cycle experience, particularly in claims, eligibility, benefits, and authorizations, and can quickly identify root-cause errors in a high-volume environment. This is an operational “fix-it” position — the manager needs someone who doesn’t just process claims but can find what’s broken and correct it without hand-holding.

Key Responsibilities:

• Perform comprehensive audits on assigned accounts to identify billing, payment, and adjustment errors.
• Correct claim discrepancies within established turnaround times.
• Ensure claim data accuracy, compliant coding, and alignment with the member’s plan benefit.
• Process claims quickly and accurately according to organizational benchmarks.
• Apply reimbursement rules based on the member’s benefits and plan specifications.
• Validate supporting documentation needed for accurate processing (eligibility, benefits, authorizations, etc.).
• Conduct follow-up on delayed, denied, or pended claims; escalate unresolved items as needed.
• Investigate processing delays, missing information, or system errors and implement corrective action.
• Refer cases to clinical management teams when medical review is required to ensure appropriate reimbursement.
• Verify and document member eligibility, benefits coverage, and authorization requirements.
• Identify discrepancies in coverage or authorizations that impact payment determinations.
• Communicate directly with payers or internal departments to resolve missing or inconsistent benefit information.
• Work closely with leadership, clinical review staff, and the CBO team to ensure timely resolution of claim issues.
• Participate in problem-solving discussions related to claim trends or systemic issues.
• Support training and onboarding efforts as needed during onsite sessions.

Required Skills & Experience:

• Minimum 2–3 years of experience in healthcare revenue cycle, claims processing, eligibility/benefits, or authorizations.
• Strong understanding of payer rules, reimbursement methodologies, and claims adjudication.
• Familiarity with Epic, payer portals, and other claims/RCM systems.
• High accuracy in auditing and error resolution work.
• Experience resolving complex claim issues across multiple systems.

Preferred Qualifications:

• Experience working in a Central Business Office or Shared Services model.
• Prior experience supporting Utah-based payer populations or multi-state payer networks.

Work Environment:

Training: Onsite at 4255 Lake Park Blvd, West Valley City, UT 84120

Ongoing Work: Remote, with one required onsite day per month

Schedule: Day shift, Non-Exempt

Compensation: $20/hr to $22/hr. Exact compensation may vary based on several factors, including skills, experience, and education. Benefit packages for this role will start on the 1st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.