Claims Adjustor

About the role

This position involves processing and resolving healthcare claims for self-funded employer groups. You will evaluate submitted claims, determine coverage based on benefit plans, and authorize payments to healthcare providers. Collaboration with various internal teams is essential to ensure accurate and timely claim resolution.

Key facts

What you'll do

• Examine and process incoming healthcare claims according to established company policies and the specific terms of client benefit plans.
• Review system-generated claim edits to verify that benefits are applied correctly and company funds are managed responsibly before releasing payments.
• Escalate claims to the Plan Build/System Configuration Team if there are questions or inconsistencies in how the system interprets plan benefits.
• Forward claims to Provider Maintenance or Pricing teams when edits cannot be resolved due to issues with provider selection, pricing, or usual and customary discrepancies.
• Deny claims for additional information when necessary, clearly communicating the required data to participants or providers, and then re-adjudicate once the information is received.
• Meet daily, weekly, and monthly production targets as outlined by the Claims Department.
• Contribute to quality improvement initiatives and propose process enhancements to increase efficiency.
• Handle claims with moderate supervision, contacting providers as needed, and meeting departmental production and quality goals.
• Take on advanced responsibilities, which may include training newer team members, participating in projects, documenting procedures, and assisting with high-value claim reviews or overpayment investigations.

Requirements

• Previous experience using a highly automated and integrated claims processing system.
• Familiarity with healthcare claims, medical coding, and benefit plan regulations.
• Strong analytical thinking abilities and the capacity to make independent judgments with minimal oversight.
• Effective verbal and written communication skills.
• Demonstrated ability to perform in a fast-paced setting, managing multiple tasks under production pressure.
• Proven capability to work independently for extended periods.
• Proficiency with Microsoft Office suite and other web-based applications.
• Aptitude for learning new proprietary computer systems.
• High School diploma or GED.

Nice to have

• Experience with HealthRules Payer.

Skills & tools

• Claims processing systems
• Medical coding
• Benefit plan administration
• Microsoft Office Suite

Practical notes

• Paid training begins October 2026.
• Overtime may be required based on business needs.
• A knowledge assessment may be part of the interview process.