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.

• 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

• 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

• 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

• Process claims within Health Rules 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

• 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

• High school diploma or equivalent
• Minimum of 3 years of medical claims processing experience

• Advanced knowledge of healthcare claims adjudication processes
• Experience using Health Rules 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)
• Me…