Claim Processor III

Medica

. Adjudicate professional and institutional medical claims from initial receipt through final determination .

Posted 9/17/2026full-timeRemote • Arizona • United StatesMid-LevelSenior💰 $37,600 - $56,385 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates advanced knowledge of healthcare claims adjudication processes, including the ability to interpret benefit plans and apply regulatory requirements. Proficient in processing claims using HealthRules and WebTPA while maintaining compliance and quality standards.

Highest-signal resume keywords

Medical Claims Processing ExperienceHealthRules ProficiencyWebTPA ExperienceAnalytical Problem-Solving SkillsUnderstanding of Coordination of Benefits

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Healthcare Claims AdjudicationMedical Billing and CodingBenefit AdministrationClaims Workflow KnowledgeProvider Pricing MethodologiesCoinsurance UnderstandingCopays UnderstandingMember Liability UnderstandingBalance Billing UnderstandingStandard Operating Procedures Interpretation

Soft Skills

Critical ThinkingAttention to DetailCollaborationCommunicationAdaptability

Tools & Technologies

Microsoft ExcelMicrosoft WordHealthRulesWebTPAExternal Pricing Portals

Industry Keywords

Healthcare OperationsClaims ProcessingCommercial Health InsuranceIndividual & Family Business ClaimsRegulatory Compliance

About the role

Key responsibilities & impact

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
Use critical thinking and sound judgment to determine appropriate claim outcomes
Escalate issues requiring additional review, coding validation, or medical review
Collaborate 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 HealthRules and price claims for WebTPA platforms
Access 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
Perform other duties as assigned

Requirements

What you’ll need

High school diploma or equivalent
Minimum of 3 years of medical claims processing experience
Advanced knowledge of healthcare claims adjudication processes
Experience using HealthRules 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)
Understanding of medical billing and coding concepts
Understanding of benefit administration
Understanding of coinsurance, copays, member liability, and balance billing
Understanding of commercial health insurance claims processing
Ability to interpret and follow detailed standard operating procedures
Strong analytical, critical thinking, and problem-solving skills
Proficiency with Microsoft Excel and Microsoft Word
Experience working with claim vendors, pricing systems, and external portals
Knowledge of healthcare operations and claims workflows
Primary home address in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, or WI
Legally authorized to work in the United States at the time of application
Medica does not offer work visa sponsorship for this role

Benefits

Comp & perks

Medical insurance
Dental insurance
Vision insurance
PTO
Holidays
Paid volunteer time off
401K contributions
Caregiver services
Competitive total rewards package