Claims Processor

Position Summary

The Claims Processor will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical and dental claims, as well as various types of invoices, based upon specific knowledge and application of each client’s customized plan(s).

• Process a minimum of 1,200 medical, dental, and vision claims per week while maintaining quality goals.
• Read, analyze, understand, and ensure compliance with clients’ customized plans.
• Learn, adhere to, and apply all applicable privacy and security laws, including HIPAA, HITECH and any regulations promulgated thereunto.
• Independently review, analyze and make determinations of claims for: reasonableness of cost; unnecessary treatment by physician and hospitals; and fraud.
• Review, analyze and add applicable notes using the Qic Link system.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Analyze claims for billing inconsistencies and medical necessity.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
• Review Workflow Manager daily to document and release pended claims, if applicable.
• Review Pend and Suspend claim reports to finalize all claim determinations timely.
• Assist and support other Claims Specialists as needed and when requested.
• Attend continuing education classes as required, including but not limited to HIPAA training.

• High School Graduate or equivalent required.

• Applicants must have a minimum of two (2) years of medical claims analysis experience (Medicare/Medicaid does not count towards the experience).
• Prior experience with a Third‑party Administrator (TPA) is highly preferred.
• Applicants must have knowledge of CPT and ICD‑10 coding.
• Applicants must have strong analytical skills and knowledge of computer systems.
• Prior experience with dental and vision processing is preferred, but not required.

• Communication
• Customer Focus
• Accountability
• Functional/Technical Job Skills

• Office setting and ability to sit for long periods of time.

• Remote

To support a smooth and efficient remote work experience, the internet connection must be provided through a cable broadband or fiber optic internet service provider with speeds of at least 100 Mbps download/25 Mbps upload. Reliable internet service is essential for staying connected and productive.

Entry level

Full‑time

Other

Insurance

Base pay range: $20.00/hr – $21.15/hr compensation is not limited to base salary. Allied values its Total Rewards and offers a competitive benefit package including medical, dental, vision, life & disability insurance, generous paid time off, tuition reimbursement, EAP, and a technology stipend.