Medical Claims Processor in at Catalyst Solutions

The Medical Claims Processor is responsible for the accurate and timely review, entry, and adjudication of medical claims in accordance with payer guidelines, benefit plan provisions, and applicable state and federal regulations. This role operates in a high-volume, production-oriented environment and requires strong attention to detail, knowledge of healthcare billing and coding standards, and the ability to work efficiently within claims processing platforms.

? Review, enter, and process medical claims (professional, institutional, and/or ancillary) accurately and within established productivity and quality standards.

? Adjudicate claims in accordance with plan benefits, provider contracts, coordination of benefits (COB) rules, and applicable regulatory requirements.

? Identify and resolve pended, denied, duplicate, and edit-flagged claims through research, documentation review, and appropriate system action.

? Validate claim documentation including member eligibility, provider information, service details, diagnosis/procedure codes (ICD-10, CPT, HCPCS), and payment readiness prior to final disposition.

? Apply knowledge of Medicare, Medicaid, and/or commercial payer guidelines to determine correct claim outcomes.

? Process appeals, adjustments, voids, and resubmissions in a timely and accurate manner.

? Work claims queues and assigned work lists to maintain productivity targets and reduce backlog.

? Coordinate with internal teams — including provider relations, member services, and quality assurance — to research and resolve claim exceptions.

? Maintain accurate documentation of claim actions and resolutions to support audit readiness and compliance.

? Identify patterns in claim errors or denials and escalate systemic issues to supervisors or quality teams.

? Adhere to all HIPAA privacy and security requirements in the handling of protected health information (PHI).

? High school diploma or equivalent required; Associate's or Bachelor's degree in a related field preferred.

? 1–3 years of experience in medical claims processing, healthcare billing, or a related payer/provider operations role.

? Working knowledge of ICD-10, CPT, and HCPCS coding systems.

? Familiarity with Medicare and/or Medicaid claims guidelines.

? Experience with claims adjudication systems (e.g., QNXT, TriZetto, FACETS, or similar platforms).

? Proficiency in Microsoft Excel and standard office applications.

? Strong attention to detail with the ability to maintain accuracy in a high-volume environment.

? Ability to meet productivity standards (e.g., claims per hour/day) consistently.

? Strong written and verbal communication skills.

? Experience with coordination of benefits (COB) and subrogation.

? Knowledge of managed care, HMO, PPO, and fee-for-service reimbursement methodologies (e.g., DRG, APC, APG, MS-DRG).

? Familiarity with HRSN (Health-Related Social Needs) or non-traditional social-care claims.

? Experience processing appeals, reconsiderations, and high-dollar claims.

? Prior experience with Power BI, SQL, or data reporting tools.

? CPC, CPMA, or other relevant coding/billing certification.

? Experience in a BPO or outsourced claims processing environment.