Healthcare Claims Specialist (Healthcare)

TL;DR

Healthcare Claims Specialist (Healthcare): Managing the end-to-end claims adjudication process with an accent on claim configuration, benefit setup, and verification of eligibility. Focus on auditing auto-adjudicated claims and ensuring compliance with state and federal regulations.

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

Company

hirify.global is a major medical division of Globe Life that provides high-technology health plans with a personalized, human approach to insurance.

What you will do

• Review and process claims within the transactional system according to plan benefits and contractual reimbursement terms.
• Manage Coordination of Benefits (COB) according to plan rules and contractual terms.
• Create, execute, and report on claim test cases to identify and remediate system defects.
• Audit manually and auto-adjudicated claims to ensure accuracy and regulatory compliance.
• Collaborate with internal departments, vendors, and providers to resolve complex problem-solving tasks.
• Develop and maintain detailed desktop procedures for the claim adjudication process.

Requirements

• Minimum 3 years of medical claim adjudication experience with a health insurance carrier or TPA.
• Knowledge of medical and insurance industry terminology, including CPT/ICD-10, HCPCS, and Revenue Codes.
• Must be based in the United States within the CST or EST time zones.
• Proficiency in Microsoft Office and experience with CRM systems, preferably Salesforce.
• Ability to maintain a secure, private dedicated work area separate from living areas.
• Strong attention to detail and ability to perform in a deadline-oriented environment.

Nice to have

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

Culture & Benefits

• Comprehensive health, dental, and vision insurance, including life and disability.
• Retirement savings plan with company match.
• Generous paid time off and vacation.
• Professional development opportunities.
• Flexible, fully remote work environment.