Sr. High Risk Claims Specialist

Location: Remote, United States

Salary: $22.00–$25.00 per hour, depending on location, skills, and experience.

Company

hirify.global provides a personalized health platform combining health plan administration, wellbeing solutions, and care navigation for employers, health plans, and health systems.

What you will do

• Review, analyze, and adjudicate complex high-dollar, healthcare, dialysis, and stop loss claims from intake through resolution.
• Apply company policies and regulatory requirements while meeting accuracy and turnaround targets.
• Review plan documents and vendor arrangements to validate system configuration before claims processing.
• Act as an escalation resource for complex claims questions and edge cases.
• Identify and escalate risks in plan documents, claims processing, and system setup.
• Manage assigned stop loss renewal activities, client and vendor questions, regulatory training, and special projects.

Requirements

• At least 4 years of experience in claims processing, adjudication, or related healthcare or insurance operations.
• At least 4 years of experience working with multiple claims processing systems.
• Thorough knowledge of medical terminology and ICD-9, CPT, and HCPCS coding.
• Proficiency with claims processing systems, Microsoft Office Suite, and reporting tools.
• A degree in Business, Healthcare Administration, or a related field is preferred; equivalent experience is considered.
• Healthcare industry experience in health insurance, medical offices, billing, or clinical operations is preferred.

Culture & Benefits

• Full benefits package available from day one.
• Medical and dental coverage through hirify.global solutions.
• Paid time off, mental health support, retirement planning, and financial protection.
• Professional development, career progression, and learning budgets.
• Mission-driven environment focused on improving health outcomes and valuing diverse perspectives.