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Claims Reviewer (Remote) ID-12727

About the Role
We are seeking a detail-oriented contract-to-hire Claims Reviewer to join our team! In this role, you will conduct retrospective reviews of medical and behavioral health claims for both inpatient and outpatient services. You will apply your clinical, coding, and processing knowledge to ensure claims are accurate, compliant, and appropriately reimbursed according to program benefits.

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Key Responsibilities

  • Perform detailed reviews of medical claims using established clinical criteria and guidelines (e.g., CDST, CPT, HCPCS, ICD-10).

  • Validate medical necessity, appropriateness of care, and adherence to program exclusions, limitations, and benefits.

  • Collaborate with medical directors, providers, and claims teams to resolve coding or clinical questions.

  • Prepare claims for payment review or escalate to medical director if necessary.

  • Identify and report potential quality or fraud issues to management and relevant departments (e.g., Quality Management, Program Integrity).

  • Review claims data to recommend process improvements and support accurate claims payment.

  • Ensure compliance with contract timelines for claims resolution.

  • Maintain consistent production standards and meet processing quotas.

  • Communicate effectively across teams to support operational excellence.

Qualifications
Required:

  • High school diploma or GED.

  • At least 2 years of claims review experience.

  • Knowledge of medical claims review processes for inpatient and outpatient services.

Preferred:

  • Coding experience with CPT, HCPCS, and ICD-10.

  • Familiarity with behavioral health claims.

Key Competencies:

  • Strong knowledge of claims processing tools such as Supercoder and Clinical Decision Support Tool.

  • Ability to evaluate clinical documentation for compliance and accuracy.

  • Organizational skills with the ability to manage multiple priorities in a fast-paced environment.

  • Effective communication and collaboration with internal and external stakeholders.

  • Proficiency in Microsoft Office Suite and department-specific applications.

Working Conditions

  • Fully remote position; must have reliable internet and a distraction-free workspace.

  • Prolonged sitting and extensive computer work required.

Why Join Us?
This is an opportunity to work in a dynamic, mission-driven environment where your skills and expertise in claims review will make a meaningful impact. We offer competitive compensation, comprehensive benefits, and a collaborative remote work culture.

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