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Company Overview

GlobalHealth, Inc. is a rapidly expanding Medicare Advantage HMO health insurance provider committed to delivering genuine care and optimal health to its members. The company prides itself on personalized, attentive, and valuable service, aiming to be more than just an insurer but a long-term partner for its members. Core values emphasize accountability, drive, innovation, and a dedication to continuous learning.

Role Summary

The Claims Processor will handle the accurate and timely processing of various contracted and non-contracted claims related to Medicare, Medicaid, and Commercial Insurance. Working closely with team leadership, the role focuses on meeting operational, departmental, and regulatory standards for quality, volume, and promptness. The position demands autonomy, excellent communication, and customer service skills.

Key Responsibilities

Process medical claims conforming to productivity and quality standards (HCFA1500 and UB92), following contractual and processing guidelines.
Collaborate with leadership for review and quality assurance of processed and pending claims.
Coordinate with Claims Manager to resolve customer service inquiries within 24 hours.
Support claims adjustment projects and assist with claims entry as needed.
Complete assigned tasks promptly and maintain up-to-date desk procedures and references.
Uphold confidentiality and security of business and Protected Health Information (PHI) in compliance with HIPAA and company policies.
Perform additional duties as assigned.

Qualifications & Experience

Minimum high school diploma or equivalent.
Preferably two years of experience in medical claims processing.

Skills & Knowledge

Comprehensive understanding of insurance processes in Managed Care, Medicare, Medicaid, and Commercial insurance.
Familiarity with medical claims processing guidelines and practices.
Knowledgeable in Medicare and Health Care Finance Administration regulations.
Experienced with EOBs, CPT, ICD-10 codes, HCFAs, UB04s, HCPCS, DRGs, and prior authorizations/referrals.
Ability to interpret provider contracts accurately.
Strong verbal, written, organizational, and analytical skills with self-motivation and problem-solving capabilities.
Proficient typing and keyboarding skills.
Capable of maintaining accuracy and detail orientation in a fast-paced environment.
Basic math proficiency.
Team collaboration mindset.

Work Environment

This position is remote, though some state restrictions may apply. Candidates must have secure and reliable internet access and ensure privacy and confidentiality standards are met per HIPAA and company protocols. Employees are required to safeguard company records against unauthorized access and follow all privacy and security policies.

Additional Information

No travel is necessary for this role. There is no supervisory responsibility. Job duties may evolve, and employees must adapt accordingly.

Claims Processor