Key Responsibilities
- Adjudicate and process complex commercial health insurance, major medical, dental, and disability claims in accordance with benefit policies.
- Verify member eligibility, coordination of benefits (COB), deductible limits, out-of-pocket maximums, and prior authorization approvals.
- Investigate disputed medical charges, provider balance billing appeals, and clean-claim compliance under state prompt pay regulations.
- Identify and report suspected Healthcare Fraud, Waste, and Abuse (FWA) patterns to the Special Investigation Unit (SIU).
What We Are Looking For
- 3+ years of health insurance claims adjudication or medical claims auditing experience.
- Proficiency navigating health plan adjudication platforms (Facets, QNXT, or HealthEdge).
- In-depth understanding of CMS-1500 and UB-04 claim forms, diagnostic codes, and ERISA regulations.
- Exceptional detail orientation and written/verbal dispute resolution skills.
Core Technologies & Methodologies
Claims Adjudication
Coordination of Benefits (COB)
CMS-1500 / UB-04
Facets
Pre-Authorization
Fraud Waste & Abuse (FWA)
ERISA
Why Build Your Career at Oakbridge?
Elite Toolsets
Direct architecture experience with Domo, Snowflake, Databricks, AWS, dbt, and modern LLM APIs.
Remote Autonomy
High-trust asynchronous collaboration, flexible hours, and healthy work-life integration.
Paid Certifications
100% funded Domo, Snowflake SnowPro, and AWS Solution Architect certifications.
Competitive Pay
Above-market salary tiers, performance bonuses, and dedicated modern hardware stipends.