Claim Processor III

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.
We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.
Medica's Claims Processor III is responsible for the accurate and timely adjudication of complex commercial and Individual & Family Business (IFB) medical claims from receipt through final resolution. This role requires advanced knowledge of claims processing, benefit administration, coordination of benefits, medical billing and coding, and healthcare industry regulations. The Claims Processor III works independently to analyze claims, apply standard operating procedures (SOPs), resolve processing issues, and collaborate with internal and external partners to ensure accurate claim outcomes. Performs other duties as assigned.
Key Responsibilities
Process Complex Medical Claims
Adjudicate professional and institutional medical claims from initial receipt through final determination
Process an average of 35 to 50 claims daily while maintaining quality and productivity standards
Review claims for coding accuracy, pricing, benefit application, eligibility, and payment determination
Analyze complex claim scenarios involving coordination of benefits, member liability, coinsurance, copays, and balance billing
Identify and resolve claim discrepancies, system issues, and payment irregularities
Apply Advanced Claims Knowledge
Interpret and apply benefit plans, policies, regulatory requirements, and internal procedures
Navigate complex claims involving high-dollar amounts, multiple service dates, specialized provider arrangements, and unique benefit situations
Utilize critical thinking and sound judgment to determine appropriate claim outcomes
Escalate issues requiring additional review, coding validation, or medical review
Collaborate Across Functions
Work closely with coders, medical review teams, auditors, analysts, account managers, and operational partners
Coordinate claim research and issue resolution with internal stakeholders
Support escalated member, provider, and client issues requiring specialized claims expertise
Share knowledge and best practices with team members
Utilize Claims Systems and Vendor Resources
Process claims within HealthRules and pricing of claims for WebTPA platforms
Access and utilize external pricing and vendor portals as needed
Work with network partners and vendors to obtain pricing and claim adjudication information
Follow established SOPs and workflow documentation to ensure processing consistency
Support Operational Excellence
Meet accuracy, turnaround time, and productivity expectations
Identify trends and opportunities to improve processes and workflows
Maintain compliance with departmental policies and regulatory requirements
Contribute to team goals and continuous improvement initiatives
Required Qualifications
High school diploma or equivalent
Minimum of 3 years of medical claims processing experience
Preferred Qualifications
Advanced knowledge of healthcare claims adjudication processes
Experience using HealthRules and/or WebTPA
Experience processing commercial and Individual & Family Business (IFB) claims
Familiarity with provider pricing methodologies and network arrangements
Understanding of:
Coordination of Benefits (COB)
Medical billing and coding concepts
Benefit administration
Coinsurance, copays, member liability, and balance billing
Commercial health insurance claims processing
Ability to interpret and follow detailed standard operating procedures
Strong analytical, critical thinking, and problem-solving skills
Proficiency with Microsoft Excel and Microsoft Word
Experience working with claim vendors, pricing systems, and external portals
Knowledge of healthcare operations and claims workflows
This position is a Remote role. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI
The full salary grade for this position is $37,600 - $64,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $37,600 - $56,385. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.
The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.
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.
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.

Work arrangement
No