Sr. Medical Claims Processor

Senior Medical Claims Processor - Job Description

The Senior Medical Claims Processor is responsible for reviewing, processing, and resolving medical insurance claims with a high level of accuracy and efficiency. This role requires a strong understanding of healthcare billing practices, coding systems, and payer guidelines to ensure timely reimbursement and compliance with industry regulations.

Key Responsibilities:

• Review, analyze, and process medical claims in accordance with insurance policies, contracts, and healthcare regulations
• Ensure accuracy of claim details, including patient information, coding (ICD-10, CPT, HCPCS), and billing data prior to submission
• Investigate and resolve denied, rejected, or pending claims by working with providers, payers, and internal departments
• Maintain compliance with HIPAA and all applicable federal, state, and payer-specific regulations
• Perform claims adjustments, corrections, and resubmissions as needed to ensure proper reimbursement
• Monitor claims processing workflows to meet productivity and quality standards
• Communicate effectively with insurance companies and healthcare providers to expedite claims resolution
• Maintain detailed documentation of claims activity, correspondence, and outcomes for audit and reporting purposes
• Identify trends in claim denials or errors and recommend process improvements to reduce rework and increase efficiency
• Provide guidance or support to junior claims processors and assist with training as needed

Qualifications:

• 3-5 years of experience in medical claims processing, medical billing, or revenue cycle management
• Strong knowledge of medical terminology, ICD-10, CPT, and HCPCS coding
• Familiarity with payer guidelines, EOBs, and claim adjudication processes
• Proficiency in claims processing systems and Microsoft Office (especially Excel)
• High attention to detail, accuracy, and problem-solving skills
• Ability to work in a fast-paced environment and manage high claim volumes
• Strong communication and organizational skills

Preferred:

• Experience with multiple insurance payers (commercial, Medicare, Medicaid)
• Knowledge of revenue cycle workflows and compliance standards