Medical Claims Consultant

Job Title: Medical Claims Consultant
Duration: 6 Months with possible extension
Location: Remote
POSITION SUMMARY:
We are seeking a detail-oriented consultant with experience processing healthcare claims using PLEXIS/ PLEXIS Claims Management System. The role will be responsible for reviewing, adjudicating, and processing medical and/or dental claims in accordance with plan benefits, contracts, policies, and regulatory requirements.
Key Responsibilities:
• Process and adjudicate healthcare claims using PLEXIS/ PLEXIS Claims Management System.
• Review claims for eligibility, member benefits, provider information, coding, authorization, and coverage requirements.
• Validate claim data and identify discrepancies, errors, duplicate claims, or missing information.
• Apply appropriate benefit plans, reimbursement rules, contractual requirements, and claim edits.
• Research and resolve pended, rejected, or suspended claims.
• Review CPT, HCPCS, ICD-10, revenue codes, modifiers, and place-of-service codes as applicable.
• Process adjustments, corrections, recoupments, and claim reprocessing.
• Coordinate with providers, members, internal departments, and other stakeholders to resolve claim issues.
• Maintain accurate documentation of claim decisions and research.
• Meet established production, quality, accuracy, and turnaround-time metrics.
• Follow HIPAA, payer policies, and applicable state and federal healthcare regulations.
• Assist with identifying recurring claim issues and escalating system or configuration problems.

Work arrangement
Yes