Claims Operations Specialist

Responsibilities:

• Oversee the full revenue cycle process for both medical and pharmacy claims, including submission, QA, payment posting and AR follow-up.
• Review, investigate and resolve claim denials and rejections to ensure timely and accurate reimbursement.
• Assist with client onboarding, including claims setup, payer integration, Candid configuration and rules engine alignment.
• Perform monthly billing operations such as claims reconciliation, bank reconciliation and revenue validation.
• Serve as a point of contact for clients, participating in onboarding calls, monthly check-ins and responding to billing questions.
• Collaborate with Sales, Product, Data and Client Success teams on RFPs, internal process updates and issue resolution.

Qualifications:

• Bachelor’s degree in Healthcare Administration, Business or a related field, or equivalent practical experience.
• CPB, CRCS or CMRS strongly preferred.
• 4+ years of experience in revenue cycle management, medical billing or claims operations.
• Experience in the digital health space is a plus.
• Prior experience using Candid or similar RCM platforms is preferred.
• Advanced Excel skills (e.g., pivot tables,VLOOKUP, formulas).
• Familiarity with BigQuery, Looker, NetSuite and Candid.
• Understanding of general healthcare reimbursement principles.
• Familiarity with pharmacy claims and/or alternative coding (eg., S-codes) preferred.

• Self-starter with a proactive approach to problem-solving.
• Strong analytical mindset with the ability to work through ambiguity.
• Comfortable working independently with minimal direction.
• Strong attention to detail and accountability for high-quality work.
• Effective communicator with experience engaging clients directly.