Healthcare Claims Specialist
Evry Healthy
Job Summary
The Healthcare Claims Specialist is a remote claims processing role focused on reviewing, paying, pending, or denying medical claims based on plan benefits and contractual reimbursement terms. This non-phone to very low-phone position includes claim adjudication, Coordination of Benefits processing, claims testing, defect reporting, auditing, and cross-functional problem solving.
Job Description
The Remote Healthcare Claims Specialist reviews and processes medical claims within a claims transactional system according to plan benefits, reimbursement terms, and established claims procedures. This role supports accurate claim outcomes by determining whether claims should be paid, pended for more information, or denied based on applicable rules and documentation.
This position fits best as a non-phone to very low-phone healthcare claims role. The job description emphasizes claims review, adjudication, Coordination of Benefits processing, test case creation, claim auditing, defect reporting, procedure writing, and virtual collaboration. Communication happens through team huddles, supervisor check-ins, instant messaging, internal departments, vendors, business partners, and providers, but the posting does not describe high-volume inbound or outbound phone work.
Daily responsibilities include reviewing claims, processing COB claims, identifying inventory issues, auditing auto-adjudicated and manually processed claims, and helping resolve claims system defects. In addition, the specialist creates claim test cases, executes testing, reports results, works with configuration teams, and retests corrected defects to support claim accuracy.
The role also requires strong documentation and process support. The Healthcare Claims Specialist develops and maintains desktop procedures related to claim adjudication while helping internal teams improve claims workflows. This makes the position a strong fit for experienced claims professionals who enjoy detailed review, system testing, quality control, and operational problem solving.
Candidates need at least three years of medical claim adjudication or examination experience with a health insurance carrier, TPA, or similar organization. Knowledge of CPT, ICD-10, HCPCS, revenue codes, claim testing, auditing, CRM systems, Microsoft Office, Salesforce, and claims-related workflows can help applicants stand out. CCS or CPC certification, Plexis experience, or Quantum Choice experience may provide additional advantages.
The salary range for this remote role is $55,000 to $60,000 annually. The company also offers health, dental, vision, life and disability insurance, retirement savings with company match, paid time off, professional development, and a flexible remote work environment.
Overall, this role works best for experienced medical claims adjudication professionals who want a remote, detail-focused position involving claims processing, claim testing, auditing, system accuracy, and healthcare operations support.