Senior Claims Researcher (Healthcare)

TL;DR

Senior Claims Researcher (Healthcare): Performing high-level technical audits and root cause research on Medicare Advantage claims to ensure payment accuracy with an accent on the intersection of provider contracts and system configuration. Focus on leveraging AI-forward strategies and LLMs to identify systemic payment trends and reduce billing friction.

Location: Remote (USA)

Salary: $107,000 - $130,000 USD

Company

hirify.global is a Medicare Advantage plan that leverages technology and data-driven insights to provide personalized, high-quality healthcare.

What you will do

• Execute monthly technical quality audits to ensure claims align with provider contracts, benefit rules, and pricing guidelines.
• Perform deep-dive root cause research in HealthEdge HRP and Source to identify configuration logic or policy misinterpretations.
• Compile and present data-driven reports highlighting enterprise risk and systemic payment trends for executive leadership.
• Provide human-in-the-loop feedback to train and refine AI and Machine Learning auditing tools.
• Collaborate with external BPaaS stakeholders and internal Configuration teams via JIRA to resolve identified errors.
• Serve as the final safeguard for adjudication accuracy, ensuring real-world output matches contractual intent.

Requirements

• 5+ years of experience in Medicare Advantage claims auditing, research, or complex adjudication.
• Current coding certification required (CPC, CCS, COC, or CIC).
• Deep technical proficiency in HealthEdge HRP and Source.
• Must be based in the USA.
• Experience and enthusiasm for using LLMs (Claude, Gemini, ChatGPT) to automate auditing processes.
• Strong communication skills for translating complex technical findings into actionable reports.

Culture & Benefits

• Competitive base salary, equity opportunities, performance bonuses, and 401k matching.
• Comprehensive medical, dental, and vision coverage.
• Remote-first culture with flexible time-off, No-Meeting Fridays, and monthly company holidays.
• Professional development funding, mentorship, and regular performance reviews.
• Additional perks including ESPP, home office reimbursement, and monthly cell phone & internet stipends.
• Paid parental leave for all new parents.