Claims Adjudication Associate

TL;DR

Claims Adjudication Associate (MedTech): Evaluating complex medical claims and benefit determinations to ensure accurate reimbursement and regulatory compliance with an accent on policy interpretation and risk assessment. Focus on resolving escalated billing disputes, supporting cross-functional operations, and improving adjudication workflows within an enterprise health platform.

Location: Hybrid (Must be local to NYC, Denver, or Charlotte area)

Salary: $82,400 – $123,500 USD (varies by location)

Company

hirify.global is an enterprise health technology company providing comprehensive pharmacy and health benefit management solutions through its proprietary Enterprise Health Platform.

What you will do

• Evaluate complex medical claims, coverage issues, and benefit determinations by reviewing plan documents and medical coding.
• Interpret complex policy language to resolve escalated or non-routine claim matters.
• Make determinations on liability, payment, subrogation, and recoupment with significant financial and operational impact.
• Serve as a subject matter expert for Customer Care and Operations teams regarding adjudication logic and inquiry management.
• Manage escalated workflows including appeals and provider inquiries based on contractual and regulatory requirements.
• Identify operational gaps and recommend process improvements to support automation and risk reduction.

Requirements

• Must be local to NYC, Denver, or Charlotte area for hybrid work.
• 2+ years of experience in health plan, TPA, or medical claims operations.
• Strong understanding of medical claims adjudication, coordination of benefits, and appeals.
• Proven ability to interpret benefit plans, coverage provisions, and applicable healthcare regulations.
• Proficiency in Microsoft Office and experience with operational platforms like Jira or Confluence.
• Ability to work effectively with virtual teams while maintaining strict confidentiality and privacy standards.

Nice to have

• Bachelor’s degree.
• Experience with Medicare or Medicaid programs.

Culture & Benefits

• Opportunity to work on a leading proprietary Enterprise Health Platform.
• Collaborative environment focused on rebuilding trust in the U.S. healthcare system.
• Commitment to equal employment opportunity and professional development.
• Engagement in cross-functional initiatives to drive high performance and process efficiency.