Senior Medical Claims Processor; Hybrid

Senior Medical Claims Processor (Hybrid)

Healthcare shouldn’t be something you worry about when taking care of your family.

That’s why when you join Redirect Health, your healthcare costs nothing out of your paycheck—and the same is true for your spouse and children.

• No monthly premiums
• No surprise medical bills

Most team members avoid tens of thousands of dollars in healthcare costs compared to traditional health plans.

This isn’t a perk.
It’s part of our mission.

Redirect Health exists to make healthcare affordable for small businesses and people who can’t afford traditional employer insurance.

We help real people navigate a system that is often confusing, expensive, and frustrating—and we do it with empathy, accountability, and simplicity.

If you want your work to matter to families every single day, you’ll find purpose here.

At Redirect Health, our values guide how we show up for each other, our clients, and our members.

We do our best work when we:

• Obsess Over People – We are always helpful, friendly, and human
• Own It to Completion – If we take something on, we see it through
• Always Improve & Adapt – We learn quickly and adjust without ego
• Start with “Yes, We Can Help You” – We lead with solutions
• Succeed as a Team – We win through trust and collaboration
• Detest Waste & Unnecessary Complexity – We simplify to focus on what matters

The Senior Medical Claims Processor is responsible for accurately reviewing, processing, and adjudicating complex medical claims in accordance with company policies, client guidelines, and regulatory requirements. This role serves as a subject matter expert, supports junior staff, and ensures timely, compliant, and high-quality claims resolution. The position also plays a key role in operational workflow oversight, provider relations, escalations, auditing, and team development.

Key Responsibilities:

Claims Processing & Adjudication:

• Review and process medical claims with a high degree of accuracy and efficiency
• Handle manual claims and complex reprocessing (routine and advanced)
• Analyze complex claims, identify discrepancies, and determine appropriate adjudication
• Interpret and apply benefit plans, coding standards (CPT, ICD-10, HCPCS), and payer guidelines
• Process Coordination of Benefits (COBs) and non-coordinated claims
• Review and process appeals, accident letters, and medical records requests
• Generate and review EOB/EOP and no-pay letters
• Manage claim settlements and follow up on single case agreements and special arrangements

Research & Issue Resolution:

• Investigate and resolve claim issues including eligibility, authorization, and billing discrepancies
• Handle escalations from internal teams, clients, and members
• Respond to provider and member inquiries (claim status, contact requests, etc.)
• Coordinate with care logistics and other departments to resolve complex issues

Provider Relations:

• Communicate with providers regarding claims, payments, and issue resolution
• Negotiate payment discrepancies and rejections (lead responsibility)
• Maintain and strengthen provider relationships through ongoing communication

Payment & Check Management:

• Review and manage check status, voids, reissues, and returned checks
• Handle recoupment letters and payment adjustments
• Support check printing and mailroom processes
• Respond to provider inquiries related to payment status

Operational Oversight:

• Oversee daily workflow to ensure timely and accurate claims processing
• Submit physical claims to the clearinghouse
• Monitor group termination dashboard and pending premium payments
• Track and manage pend statuses (e.g., MOOP limits, visit limits, shareable limits)
• Maintain newborn eligibility tracking and non-coordinated lists

Auditing & Reporting:

• Conduct weekly and…