Healthcare Claims Processor (Fully Insured)

Introduction:

Elite Technical Services is partnering with a major healthcare insurance provider to identify motivated, detail-oriented Medical Claims Processors to join their Fully Insured operational team. This specialized track is responsible for establishing the baseline adjudication and processing engine for core commercial health insurance plans. This is a fast-paced, high-volume production environment well-suited for professional processors who possess sharp medical coding knowledge and exceptional systems navigation skills.

Responsibilities:

• Review, investigate, and adjudicate standard commercial and fully insured medical claims efficiently and accurately.
• Validate incoming provider billing codes, including ICD-10, CPT, and HCPCS coding structures, against member benefit data.
• Navigate the Facets core claims platform to verify policy enrollment, premium tracking, deductibles, and co-insurance accumulators.
• Manage standard claims processing queues, resolving systematic pend reasons to clear backlogs.
• Ensure strict adherence to internal performance metrics, quality assurance thresholds, and compliance timelines.
• Document claim determinations clearly within the system log files when manual intervention or adjustment is necessary.

Requirements:

Required Education: HS Diploma

Required experience: 3+ years of hands-on experience in medical claims processing and adjudication is strictly required.

Prior experience: utilizing the Facets core claims processing platform is highly preferred, specifically G6 and/or 360

Skills:

• Strong fundamental knowledge of healthcare insurance operations, medical terminology, and standard adjudication workflows.
• Proven ability to maintain consistent production speed and high data accuracy rates in a high-volume metric-driven environment.
• Strong organizational skills with a high attention to detail and sharp analytical problem-solving abilities.