[Hiring] Claim Appeals & Correspondence II @Medica

Role Description

The Claim Appeals & Correspondence II position is responsible for managing assigned inventory related to claim appeals, customer service concerns, internal inquiries, and escalated VIP issues. This intermediate-level role supports post-adjudication claims operations by researching, analyzing, and resolving claim processing issues with limited supervision. The position works collaboratively with cross-functional partners to resolve claim decisions and questions while supporting accurate and timely outcomes. Performs other duties as assigned.

• Manage daily inventory of claim appeals, customer service issues, internal inquiries, and escalated VIP cases
• Research, analyze, and resolve claim processing issues and questions
• Review claims to identify processing discrepancies and determine appropriate next steps
• Manage assigned reports, work baskets, correspondence, email assignments, and special projects through completion
• Collaborate with PNOM, 1st Pass Claims, PI, Coding, Configuration, and other departments as needed to resolve claim decisions and questions
• Independently manage moderately complex administrative responsibilities with limited supervision
• Provide timely responses and updates regarding open claims, inquiries, and escalated cases
• Maintain effective working relationships with internal business partners
• Meet established quality, productivity, and inventory management expectations
• Support process improvement efforts that promote claims accuracy and operational efficiency

Qualifications

• High school diploma or equivalent
• 2 years of related work experience

Requirements

• Experience in health insurance, healthcare administration, or claims operations
• Experience researching, adjusting, or reprocessing medical claims
• Knowledge of Medicare and Medicaid programs
• Understanding of Coordination of Benefits (COB)
• Experience managing high-volume inventories, queues, work baskets, or case management systems
• Knowledge of commercial and government healthcare claims
• Experience working collaboratively across claims-related operational functions

Skills and Abilities

• Strong analytical and problem-solving skills with the ability to research and resolve moderately complex issues
• Ability to work independently with limited supervision
• Basic proficiency in Microsoft Excel, including sorting, filtering, and working with spreadsheets
• Strong verbal and written communication skills
• Strong customer service and relationship-building skills
• Ability to manage multiple priorities and assigned inventory in a fast-paced environment
• Strong attention to detail and accuracy
• Ability to collaborate effectively across departments

Benefits

• Competitive medical, dental, and vision plans
• PTO and Holidays
• Paid volunteer time off
• 401K contributions
• Caregiver services
• Generous total rewards package

Eligibility to Work in the US

Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

Equal Opportunity Employer

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.