Certified Claims Processor

All Care Health Headquarters, Grants Pass, OR, US

6 days ago Requisition

Salary Range: $20.00 To $24.00 Hourly

All Care Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

The Certified Claims Processor I is responsible for independently adjudicating professional claims in accordance with company policy, contract language, and applicable regulatory guidelines. This role applies coding knowledge and established claims processing standards to resolve standard and moderately complex claims while ensuring accuracy, compliance, and timely adjudication.

• Independently adjudicates professional claims (CMS-1500) by applying benefits, pricing, coding guidelines, and contract terms.
• Utilizes knowledge of CPT, HCPCS, and ICD-10 coding to ensure accurate claims processing.
• Reviews and resolves pending claims, identifying errors and determining appropriate corrective action.
• Ensures compliance with company policy, provider contracts, and applicable Medicare/Medicaid regulations.
• Maintains established quality, accuracy, and production standards.

• Processes professional claims across multiple lines of business by reviewing claim and line-level details to ensure accurate adjudication in accordance with established policies and procedures.
• Interprets and applies coding guidelines (CPT, HCPCS, ICD-10), benefit plans, and contract language to determine appropriate claim outcomes, including pricing, payment, and denial decisions.
• Reviews and resolves claim edits, denials, adjustments, and reprocessing requests by analyzing claim and line-level data, including potential coding discrepancies, system configuration issues, or policy misalignment.
• Applies benefit plans, reimbursement methodologies, and regulatory requirements to ensure accurate outcomes.
• Evaluates pending claims to identify root causes of processing issues, including eligibility discrepancies, authorization requirements, or billing errors, and determines appropriate corrective actions.
• Coordinates benefits by reviewing member eligibility, other insurance information, and payer responsibility to ensure accurate application of coordination of benefits (COB) rules.
• Reviews provider disputes, reconsiderations, and appeals by analyzing original claim processing, supporting documentation, and applicable policies to determine if reprocessing or adjustment is warranted.
• Applies knowledge of reimbursement methodologies, fee schedules, and pricing logic to ensure claims are paid in accordance with contract terms and regulatory guidelines.
• Identifies trends or recurring issues in claim processing, including system errors, configuration gaps, or provider billing patterns, and escalates findings to leadership as appropriate.
• Communicate effectively with internal teams and providers to clarify claim details, explain adjudication outcomes, and resolve processing issues in a professional and timely manner.
• Maintains compliance with HIPAA and protects PHI by ensuring all claim handling, communication, and documentation meet confidentiality and security standards.
• Adheres to claim routing, inventory control procedures, and workflow processes to ensure timely and accurate claim processing within established turnaround times.
• Participates in ongoing training and continuing education to maintain coding certification and stay current with changes to coding guidelines, reimbursement methodologies, and regulatory requirements.
• Maintains punctual, regular, and predictable attendance while meeting established productivity and quality benchmarks.
• Respectfully takes direction from Department leadership.
• Performs other duties as assigned.

This position does not have any on-call responsibilities.

This position does not have any supervisory responsibilities.

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals…