Senior Medical Claims Processor (Hybrid)

• 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 

• 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 

• Communicate with providers regarding claims, payments, and issue resolution 
• Negotiate payment discrepancies and rejections (lead responsibility) 
• Maintain and strengthen provider relationships through ongoing communication 

• 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 

• 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 

• 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 

• 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 

• 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 

• CPC, CCS, or other relevant certification 
• Experience in auditing or quality assurance 
• Prior experience in a senior or lead claims role 

• 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 

• Hybrid work environment 
• High-volume, fast-paced, deadline-driven setting 
• Extended screen time required 

Why Join Redirect Health

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.

The pay range for this role is:

50,000 - 55,000 USD per year (Phoenix)