Individual Market CIR Claims Processor III

Workforce Classification:
Telecommuter
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Join our team as an IM CIR Claims Processor III and play a key role in ensuring claims are reviewed, researched, and resolved with accuracy, care, and confidence. In this role, you’ll apply your claims expertise to support complex problem-solving, strengthen the customers’ experience, and serve as a trusted resource for teammates through technical guidance, quality-focused work, and collaboration across internal and external partners.

The IM CIR Claims Processor III is responsible for the accurate and timely review, research and resolution of moderate to complex claims in accordance with contracts and policies. This may include Medicare, Department of Social & Health Services (DSHS), subrogation, or coordination of benefits for dental, medical and hospital claims, as well as large dollar medical and reprocessing of claims. Incumbent is responsible for interpreting procedures and policies to ensure accurate claims resolution.
What you will do:

- Review, research, and resolve claims in accordance with contracts and policies through the utilization of reference materials and on-line tools.

- Identify, research, and resolve coordination of benefits, subrogation and general inquiry issues and communicate the results.

- May complete claim adjustments, reversals and/or refunds.

- Act as the team technical subject matter expert including training and auditing trainee claims and providing appropriate feedback and technical support.

- Keep reference materials updated.

- Develop and maintain excellent relationships with both internal and external customers through the use of both written and verbal communications. This will include making outbound calls as well as receiving inbound calls.

- Prepare formal history reviews.

- Consistently meet cycle time/productivity goals that are aligned with corporate objectives.

- Maintain confidentiality of all documents/files.

- Other duties or special projects as assigned.

- Translate data into information acceptable to the claims processing system including follow up on pended claims.

- Apply commitment to quality by doing things right the first time in order to avoid defects from reaching customers or requiring internal re-work.

What you will bring:

- High School diploma or GED (Required).

- One (1) year of claims processing experience or customer service experience (Required).

- Understanding of Out-of-area programs.

- In-team focused audit experience.

What you will gain:

Complex Claims Analysis – Strengthen the ability to research, interpret, and resolve moderate to complex claims using contracts, policies, reference materials, and online tools.

Policy and Procedure Interpretation – Continue to build confidence in applying claims processing standards, regulatory requirements, benefit rules, and internal guidelines to ensure accurate outcomes.

Technical Subject Matter Expertise – Develop a deeper expertise as a go-to resource for the team by providing technical support, training, auditing trainee claims, and offering quality-focused feedback.

Customer and Partner Communication – Enhance written and verbal communica