Full Risk Claims Specialist - Remote

Overview

The Full Risk Claims Specialist - Remote role at Talentify.io is an exciting opportunity to join a top healthcare services organization recognized as one of the "Best Places to Work in the Bay Area". This role offers flexible remote work options, career advancement, and the chance to contribute to the future of healthcare through managed care.

Job Responsibilities

• Adjudicate and adjust full risk claims including MS DRG Inpatient Hospital and Home Health Care.
• Ensure claims are processed accurately and timely per health plan coverage.
• Identify billing patterns and processing errors affecting claims adjudication.
• Conduct second-level reviews of Medicare denials and resolve claim disputes.
• Document follow-up actions and generate appropriate correspondence.

Qualifications

Required: Minimum 3 years experience in claims-payment adjudication at an HMO or Health Plan, High School Diploma or GED, experience with full risk claims, and knowledge of CPT, Revenue codes, ICD-10 codes, and MS DRGs.

Preferred: Familiarity with CMS and DMHC rules, proficiency with Microsoft applications, experience with UB-04 and CMS 1500 claim forms, and strong interpersonal skills.

Key Skills/Competency

• Claims Adjudication
• MS DRG
• Healthcare Services
• CPT Codes
• ICD-10
• Revenue Codes
• Medicare Denials
• CMS Regulations
• MS DRG Inpatient
• Remote Work