Claims Representative - EviCore.

Accountabilities:

Review medical records, authorization documentation, and claim information to support post-service medical necessity reviews.
Verify member eligibility, benefits, coverage, authorization status, and applicable claim requirements.
Build and maintain authorization cases, ensuring relevant clinical documentation is collected, organized, and attached for review by licensed clinical staff.
Process claims related to radiology, pain management, laboratory services, gastroenterology, and other designated medical specialties in accordance with established procedures.
Adjudicate claims and process necessary adjustments based on authorization information and clinical review outcomes.
Investigate and resolve claim discrepancies, missing information, and pending claim inventories to ensure timely processing.
Create and manage ECRM tickets and other operational workflows to facilitate claim resolution.
Maintain compliance with client requirements, benefit plans, internal policies, and applicable regulatory guidelines.
Consistently meet established productivity, quality, accuracy, and service performance targets.
Requirements:
High school diploma or equivalent required.
Previous experience in medical claims processing, healthcare operations, or provider issue resolution is preferred.
Working knowledge of medical terminology, CPT and ICD-10 coding, and health insurance claims processing is an advantage.
Ability to interpret benefit plans, policy language, coverage requirements, and authorization documentation.
Experience with claims management systems such as MC400, ICE, NASCO, and ImageOne is a plus.
Proficiency in Microsoft Office applications, particularly Outlook, Excel, and Word.
Ability to navigate multiple applications simultaneously and work effectively in a virtual environment using Microsoft Teams, Cisco WebEx, Outlook, and similar tools.
Strong attention to detail, analytical thinking, and problem-solving skills, with the ability to identify inconsistencies and missing information.
Excellent written and verbal communication skills, combined with a collaborative and customer-focused approach.
Strong organizational and time-management skills, with the ability to manage multiple priorities while maintaining accuracy and productivity.
Self-motivated, adaptable, accountable, and comfortable working toward measurable performance objectives.
Reliable home internet connection through a cable broadband or fiber optic provider, with minimum speeds of 10 Mbps download and 5 Mbps upload.
Important: This role supports the medical necessity review process but does not involve making medical necessity determinations or approving or denying authorizations. Those decisions remain the responsibility of licensed clinical staff.
Benefits:
Compensation: Competitive hourly pay ranging from $17.75 to $24 USD, depending on experience, qualifications, and geographic location.
Annual bonus: Eligibility to participate in an annual bonus plan.
Remote flexibility: Fully remote, work-from-home position within the United States.
Healthcare coverage: Medical, dental, and vision insurance, effective from the first day of employment.
Well-being support: Access to behavioral health and wellness programs.
Retirement planning: 401(k) retirement savings plan.
Financial protection: Company-paid life insurance.
Paid time off: At least 18 days of paid time off annually, in addition to paid holidays.
Additional leave: Access to various leave-of-absence programs.
Professional development: Tuition reimbursement opportunities to support continued learning and career growth.