Job Overview Vaya Health, a leading managed care organization dedicated to behavioral health and intellectual/developmental disabilities services in North Carolina, is seeking a skilled Medical Claims Specialist to join our remote team. In this full-time role, you will play a critical part in ensuring accurate processing, adjudication, and payment of medical claims, supporting our mission to deliver high-quality, compassionate care to our members across the state. Key Responsibilities Review and analyze incoming medical claims for completeness, accuracy, and compliance with regulatory guidelines, payer policies, and contractual agreements. Adjudicate claims using established criteria, including verifying eligibility, coding accuracy (ICD-10, CPT, HCPCS), medical necessity, and authorization requirements. Investigate and resolve claim discrepancies, denials, and appeals by collaborating with providers, members, and internal teams. Process payments and adjustments promptly to minimize delays in reimbursements. Maintain detailed records in claims management systems and generate reports on claim status, trends, and performance metrics. Stay updated on evolving healthcare regulations, such as Medicare, Medicaid, and NC Medicaid managed care rules, to ensure adherence. Provide exceptional customer service by responding to inquiries from providers and members regarding claim status and issues. Required Qualifications High school diploma or equivalent required; Associate's or Bachelor's degree in healthcare administration, medical billing, or related field preferred. Minimum of 2-3 years of experience in medical claims processing, adjudication, or billing in a healthcare setting, preferably with managed care or behavioral health focus. Certification as a Certified Professional Coder (CPC) or Certified Professional Biller (CPB) strongly preferred. In-depth knowledge of medical terminology, anatomy, physiology, and coding systems (ICD-10, CPT, HCPCS). Proficiency with claims processing software such as Availity, Change Healthcare, or similar systems. Skills Exceptional attention to detail and analytical skills to identify errors and discrepancies in high-volume claims. Strong problem-solving abilities to handle complex denials and appeals effectively. Excellent communication skills, both written and verbal, for interacting with diverse stakeholders. Proficiency in Microsoft Office Suite, particularly Excel for data analysis and reporting. Ability to multitask in a fast-paced environment while maintaining accuracy and meeting deadlines. Solid understanding of HIPAA privacy rules and healthcare compliance standards. Company Info Vaya Health is a not-for-profit organization proudly serving North Carolina communities by managing behavioral health services for over 1.4 million Medicaid beneficiaries. Our innovative approach integrates physical, behavioral, and long-term services to promote whole-person care and recovery. Benefits We offer competitive compensation, comprehensive health insurance (medical, dental, vision), 401(k) with company match, generous paid time off, remote work flexibility, professional development tuition reimbursement, and employee wellness programs. Growth Opportunities Advance your career through ongoing training in claims automation, leadership development programs, and opportunities to specialize in areas like provider relations or compliance auditing. Join a supportive team committed to your professional growth in the evolving healthcare landscape.