Medical Billing Processor
Automate your job search with Sonara.
Submit 10x as many applications with less effort than one manual application.1
Reclaim your time by letting our AI handle the grunt work of job searching.
We continuously scan millions of openings to find your top matches.
Job Description
About Us
We provide skilled nursing facilities and other long-term care facilities with a concierge platform for in-facility healthcare services funded through a supplemental accident and sickness policy (Enhanced Plan). Our program enables residents to access robust medical services-often beyond what traditional Medicaid structures provide-while helping facilities maximize healthcare options for patient care.
We are committed to improving healthcare access and financial sustainability for long-term care providers through innovative insurance solutions.
Your Role
The Claims Adjuster investigates, evaluates, and resolves complex, high-dollar, or disputed health insurance claims. This role conducts detailed reviews of medical documentation, benefits coverage, and contractual terms to determine liability and negotiate equitable resolutions while maintaining regulatory compliance and protecting plan integrity.
What you'll be doing
- Complex Case Investigations: Handle escalated claims involving multi-layer benefits, COB, subrogation, prior authorization disputes, and medical necessity.
- Evidence Review: Analyze medical records, clinical notes, coding, authorization history, and provider contracts to determine claim outcomes.
- Determinations & Negotiations: Make coverage and payment decisions; negotiate settlements with providers; recommend denials or adjustments with clear rationale.
- Fraud/Waste/Abuse (FWA): Identify potential FWA indicators; coordinate with SIU for further review; document findings.
- Appeals & Grievances: Prepare case files, decision letters, and summaries for internal and external appeals; represent the organization in hearings when needed.
- Stakeholder Collaboration: Work closely with medical management, UM, provider relations, legal/compliance, and finance on complex cases.
- Policy & Compliance: Ensure adherence to HIPAA, CMS, state regulations, ERISA (as applicable), and internal policies.
- Training & Mentorship: Provide guidance to Claims Processors; contribute to SOP updates and best practices.
What you'll bring
- Associate's or Bachelor's degree preferred; equivalent experience considered.
- 3+ years in health insurance claims, with emphasis on complex adjudication, appeals, or investigations.
- Medicaid/Medicare claims experience
- Proficiency with claims platforms (e.g., Facets, QNXT, Epic Tapestry), EDI (837/835), medical record review tools, and MS Office. Microsoft Dynamic Preferred.
- Strong knowledge of ICD-10, CPT/HCPCS, DRGs, NCCI edits, medical necessity policies, CMS/state rules, ERISA (as applicable).
- Experience in provider contract interpretation, SIU/FWA, or utilization management.
Automate your job search with Sonara.
Submit 10x as many applications with less effort than one manual application.