Position Overview

Our client, a growing Third-Party Administrator (TPA) specializing in Health & Welfare benefits administration, is seeking a detail-oriented Medical Claims Processor to join their team. This administrative role is responsible for reviewing, processing, and adjudicating medical claims in accordance with plan provisions, eligibility requirements, and client-specific guidelines. The ideal candidate will have strong organizational skills, a high level of accuracy, and experience within medical claims, benefits administration, or the insurance industry.

Key Responsibilities

• Review and process medical, dental, vision, and other Health & Welfare claims accurately and timely.
• Verify participant eligibility, coverage, and claim details based on plan provisions.
• Ensure claims are adjudicated in accordance with client plans, policies, and established procedures.
• Research and resolve claim discrepancies, missing information, and processing issues.
• Communicate with providers, participants, and internal departments regarding claim status and benefit questions.
• Maintain accurate claim records and supporting documentation within the administration system.
• Assist with quality control reviews, audits, and compliance-related activities.
• Escalate complex claims or unusual situations to management as needed.
• Support ongoing process improvement initiatives and departmental goals.
• Maintain confidentiality and compliance with HIPAA and other applicable regulations.

Qualifications

• High school diploma or equivalent required; Associate's or Bachelor's degree preferred.
• 1-3+ years of experience in medical claims processing, benefits administration, insurance, or a related field.
• Understanding of Health & Welfare benefit plans and medical claims administration.
• Familiarity with medical terminology, eligibility verification, EOBs, and claims workflows preferred.
• Strong attention to detail and commitment to accuracy.
• Excellent organizational and time management skills.
• Proficiency in Microsoft Office, including Outlook and Excel.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong verbal and written communication skills.

Preferred Experience

• Experience working for a TPA, insurance carrier, health plan, or employee benefits organization.
• Exposure to self-funded employer health plans.
• Experience with claims administration platforms and benefits management systems.