Senior High Risk Claims Specialist

To ensure accurate and timely processing of high-stakes claims, the full-time Senior High Risk Claims Specialist will adjudicate complex healthcare claims, enforce compliance standards, and manage production targets while serving as a resource for the claims team. Key responsibilities Adjudicate high-dollar and specialty claims from intake through resolution, ensuring accuracy and compliance Enforce quality standards by examining claims against company policies and regulatory requirements Guide the claims team through escalations and serve as a point of contact for clients and vendors Required qualifications Degree in Business, Healthcare Administration, or a related field preferred; equivalent work experience considered 4+ years of experience in claims processing, adjudication, or related healthcare/insurance operations Thorough knowledge of medical terminology and coding (ICD-9, CPT, HCPCS) Proficiency with claims processing systems and Microsoft Office Suite Healthcare industry background preferred, including health insurance or clinical operations experience