Claims Adjudicator

Job Overview

We are seeking a highly capable and detail-oriented Claims Adjudicator to join our team who will pay claims and answer incoming member and provider calls. This role plays a key part in the accurate, timely, and compliant adjudication of medical, dental and vision claims for multiple group health plans. The ideal candidate is proactive, analytical, and dependable — someone who understands the nuances of benefit interpretation and can serve as a point of reference for peers.

This position requires an individual who can work independently and as a team while also collaborating with various departments to ensure claim processing standards are met and exceeded. Experience with both institutional (UB-04/CMS-1450) and professional (CMS-1500) claims is essential. The ideal candidate will be detail-oriented, possess excellent organizational skills, and have a solid foundation in medical documentation and billing practices.

Key Responsibilities:

• Review, analyze, and adjudicate medical and vision claims in accordance with plan documents, policies, and industry standards.
• Utilize knowledge of DRG, CPT coding, ICD-9, ICD-10, HCPCS, and medical billing to ensure proper claim processing.
• Interpret complex benefit language and apply judgment in determining appropriate claim outcomes.
• Enter and verify claim information in the system with a high degree of accuracy.
• Respond to telephone and written inquiries from providers, members, and internal departments in a timely and professional manner.
• Identify discrepancies, research data issues, and make necessary adjustments or referrals for resolution.
• Process electronic and paper claims and maintain data integrity across systems.
• Generate and review provider correspondence, including system-generated letters and explanation of benefits (EOBs).
• Collaborate with internal teams to support compliance, audit readiness, and customer satisfaction goals.
• Support continuous improvement by identifying process inefficiencies and contributing to best practice discussions.

Qualifications:

• High school diploma or equivalent required; associate degree or higher in a related field preferred.
• Minimum of 3–5 years of experience in medical claims adjudication.
• In-depth knowledge of medical billing and coding, including CPT, HCPCS, ICD-10, and CDT.
• Proficiency in interpreting benefit plan documents and EOBs.
• Familiarity with UB-04/CMS-1450 and CMS-1500 forms.
• Experience with claim systems and TPA platforms preferred.
• Strong data entry and documentation accuracy.
• Excellent communication and critical thinking skills.
• Ability to work independently, prioritize tasks, and meet processing benchmarks.

Core Competencies:

• Strong understanding of claims adjudication practices and healthcare industry standards.
• Effective communication with internal teams, providers, and clients.
• Ability to interpret complex benefit structures and apply policy accurately.
• Proficient in Microsoft Office Suite (Word, Excel) and other business tools.
• Strong organizational and time management skills.
• Consistently meets deadlines and performance metrics.
• Willingness to stay current on industry trends, coding updates, and payer requirements.

Tools & Systems Used:

• Aetna Systems, FCHN Systems, Pricing Vendors Systems, Premera Document Viewer.
• Microsoft Office Suite (Word, Excel, Outlook).
• Proprietary Internal claims processing platforms and document management systems.

Scope of Work:

• Adjudicate medical, dental, and vision claims for self-funded employer groups.
• Handle provider and member phone calls and inquiries regarding claim status, PPO networks, and coverage details and any claim issues.
• Contribute to quality assurance efforts and knowledge-sharing within the team.

Job Type: Full-time

Pay: From $26.41 per hour

Expected hours: 39 per week

Benefits:

• 401(k)
• Flexible spending account
• Health insurance
• Paid time off
• Prescription drug insurance

Work Location: In person

Salary : $26