About This Role
The Senior Medical Claims Processor is responsible for accurately reviewing, processing, and adjudicating complex medical claims in accordance with company policies, client guidelines, and regulatory requirements. This role serves as a subject matter expert, supports junior staff, and ensures timely, compliant, and high-quality claims resolution. The position also plays a key role in operational workflow oversight, provider relations, escalations, auditing, and team development.
Key Responsibilities:
Claims Processing & Adjudication:
- Review and process medical claims with a high degree of accuracy and efficiency
- Handle manual claims and complex reprocessing (routine and advanced)
- Analyze complex claims, identify discrepancies, and determine appropriate adjudication
- Interpret and apply benefit plans, coding standards (CPT, ICD-10, HCPCS), and payer guidelines
- Process Coordination of Benefits (COBs) and non-coordinated claims
- Review and process appeals, accident letters, and medical records requests
- Generate and review EOB/EOP and no-pay letters
- Manage claim settlements and follow up on single case agreements and special arrangements
Research & Issue Resolution:
- Investigate and resolve claim issues including eligibility, authorization, and billing discrepancies
- Handle escalations from internal teams, clients, and members
- Respond to provider and member inquiries (claim status, contact requests, etc.)
- Coordinate with care logistics and other departments to resolve complex issues
Provider Relations:
- Communicate with providers regarding claims, payments, and issue resolution
- Negotiate payment discrepancies and rejections (lead responsibility)
- Maintain and strengthen provider relationships through ongoing communication
Payment & Check Management:
- Review and manage check status, voids, reissues, and returned checks
- Handle recoupment letters and payment adjustments
- Support check printing and mailroom processes
- Respond to provider inquiries related to payment status
Operational Oversight:
- Oversee daily workflow to ensure timely and accurate claims processing
- Submit physical claims to the clearinghouse
- Monitor group termination dashboard and pending premium payments
- Track and manage pend statuses (e.g., MOOP limits, visit limits, shareable limits)
- Maintain newborn eligibility tracking and non-coordinated lists
Auditing & Reporting:
- Conduct weekly and bi-weekly claims audits
- Perform zero report updates and quality audits
- Ensure compliance with internal policies, client guidelines, and regulatory requirements (e.g., HIPAA)
- Maintain detailed documentation of claim decisions and actions taken
Leadership & Team Support:
- Serve as the first point of contact for team support, questions, and issue resolution
- Act as an escalation point for complex or high-value claims
- Mentor and support junior claims processors; provide training and guidance
- Conduct initial performance coaching and development discussions
- Lead or provide backup support for daily team huddles
- Participate in quality assurance reviews and process improvement initiatives
Qualifications:
- High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred
- 3–5+ years of medical claims processing experience
- Strong knowledge of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance concepts
- Experience with EHR/claims processing systems and payer platforms
- Familiarity with Medicare, Medicaid, and commercial insurance guidelines
- Experience handling complex claims, appeals, and provider negotiations
- Leadership or mentoring experience preferred
Skills & Competencies:
- Strong analytical and problem-solving skills
- High attention to detail and accuracy
- Ability to interpret complex policies and documentation
- Excellent time management and organizational skills
- Effective written and verbal communication
- Ability to work independently and manage high-volume workloads
- Leadership and mentoring capabilities
Preferred Qualifications:
- CPC, CCS, or other relevant certification
- Experience in auditing or quality assurance
- Prior experience in a senior or lead claims role
Work Environment:
- Hybrid work environment
- High-volume, fast-paced, deadline-driven setting
- Extended screen time required
Why Join Redirect Health
What “Free Healthcare” Actually Means
When we say free, we mean no money out of your paycheck and no cost when you need care:
- No monthly premiums
- No cost to add your spouse or children
- No deductibles (we reimburse them)
- No out-of-pocket maximums
This benefit alone can save families tens of thousands of dollars.
What You’ll Earn
- Salary range: $50,000 - $55,000
- FREE healthcare for you and your entire family
- Dental & Vision insurance
- Paid time off & sick time
- 401(k) access
- A mission-driven team that believes in doing the right thing
Ready to Make a Difference?
If you’re looking for more than just a job—and want to help reshape how healthcare works for families—we’d love to hear from you.
Legal Stuff
Redirect Health is an Equal Opportunity Employer (EOE). Employment with Redirect Health is at-will. Nothing in this job posting or the application process creates a contract or guarantee of employment. Please note this job description is not designed to contain a comprehensive listing of activities, duties, or responsibilities required for this role. Duties, responsibilities, and activities may change at any time with or without notice. Redirect Health does not provide employment-based visa sponsorship now or in the future for this position. Applicants must be currently authorized to work in the United States without sponsorship.
The pay range for this role is:
50,000 - 55,000 USD per year (Phoenix)