Healthcare Claims Specialist (Healthcare)

TL;DR

Healthcare Claims Specialist (Medical Billing): Reviewing and processing healthcare claims based on plan benefits and contractual terms with an accent on medical coding accuracy and quality standards. Focus on executing claim test cases, auditing auto-adjudicated claims, and collaborating with internal configuration teams to resolve defects.

Location: Must live in the United States within the CST or EST time zones

Salary: $55,000 - $60,000 a year

Company

hirify.global is a fully remote organization specializing in healthcare claims processing and administrative services.

What you will do

• Review and process claims in the transactional system according to benefits and reimbursement terms.
• Manage claims subject to Coordination of Benefits (COB) rules and contractual terms.
• Create, execute, and report on claim test cases to identify and remediate system defects.
• Audit both manually processed and auto-adjudicated claims to maintain quality standards.
• Develop and maintain desktop procedures for claim adjudication.
• Collaborate with vendors, providers, and internal units like Customer Service and Medical Management.

Requirements

• Minimum 3 years of medical claim adjudication experience with a health insurance carrier or TPA.
• Proficiency in medical terminology including CPT/ICD-10, HCPCS, and Revenue Codes.
• Must be based in the US within the CST or EST time zones.
• Experience with CRM tools, preferably Salesforce.
• Ability to work in a virtual environment with a dedicated, private workspace and high-speed internet.
• Strong proficiency in Microsoft Office (Word, Excel, Outlook, OneNote).

Nice to have

• CCS (Certified Coding Specialist) or CPC (Certified Coding Professional) certification.
• Experience with Plexis or Quantum Choice.

Culture & Benefits

• Comprehensive health, dental, and vision insurance, plus life and disability coverage.
• Retirement savings plan with company match.
• Generous paid time off and vacation.
• Fully remote work environment with flexible arrangements.
• Opportunities for professional development.