Medicare Claims Processor

WVU Medicine

. Review and oversee adjudication of Medicare insurance claims ranging from simple data entry to complex specialty claim research .

Posted 9/17/2026full-timeRemote • United StatesJuniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medicare claims processing, including adjudication, analysis, and compliance with CMS guidelines. Proficient in customer service and effective communication while maintaining patient confidentiality according to HIPAA standards.

Highest-signal resume keywords

Medicare Claims ProcessingCMS Guidelines ComplianceClaims AdjudicationCustomer Service ExperienceMedical Insurance Terminology

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AnalysisData EntryQuality ControlBenefit Eligibility DeterminationMathematics for Claims AdjudicationProcedure and Diagnosis CodesClaims Billing and ProcessingError CorrectionRecord MaintenanceEOB Interpretation

Soft Skills

Effective CommunicationInterpersonal SkillsProblem SolvingMentorshipTelephone Etiquette

Tools & Technologies

EPIC Software

Industry Keywords

Healthcare ClaimsMedicare InsurancePHI ComplianceHIPAA GuidelinesInstitutional Claims

About the role

Key responsibilities & impact

Review and oversee adjudication of Medicare insurance claims ranging from simple data entry to complex specialty claim research
Analyze and process insurance claims, checking validity in accordance with all CMS guidelines
Screen, review, evaluate online entry, correct errors, and perform quality control for final adjudication of paper/electronic claims
Ensure accuracy of data entered and maintain records
Analyze claims to determine the extent of insurance carrier liability
Resolve claim edits, review history records, and determine benefit eligibility for services
Review payment levels and arrive at final payment determinations
Interpret contract benefits and adjudicate claims according to Medicare claims processing guidelines
Meet production and quality standards and maintain work queues according to department standards
Communicate effectively with internal and external colleagues
Elevate issues to the next level of supervision as appropriate
Attend required training classes and demonstrate proficiency and ability to learn
Read and interpret explanations of benefits (EOBs)
Provide mentorship to less experienced staff as assigned by leadership
Maintain patient/member confidentiality according to PHI and HIPAA guidelines

Requirements

What you’ll need

Associate Degree in related healthcare field OR high school diploma or equivalent AND three (3) years of healthcare claims billing and processing experience
One (1) year of Medicare claims processing experience
One (1) year of experience working with CMS/professional and UB/institutional claims
One (1) year of customer service experience
Ability to determine whether to return, deny, or pay claims while following organizational policies and procedures
Working knowledge of administrative and clerical procedures and systems, including word processing and managing files and records
Ability to take direction and navigate multiple systems simultaneously
Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette
Ability to solve problems with predefined methods and guidelines
Ability to use mathematics to adjudicate claims
Ability to understand medical insurance requirements for payment and basic knowledge of covered services
Working knowledge of Medicare medical insurance terminology, procedure and diagnosis codes, and HIPPA requirements
Ability to sit for extended periods of time
Comfortable working at times with limited social interaction
Bachelor’s degree in medical coding or related healthcare field OR four (4) years of equivalent industry work experience preferred
Three (3) years of Medicare claims processing experience preferred
Three (3) plus years of medical or institutional claims processing and customer service experience preferred
Experience in Medicare medical insurance and Medicare supplement preferred
Familiarity navigating EPIC software programs preferred

Benefits

Comp & perks

Full-time schedule: 40 scheduled weekly hours
Non-exempt employment status