Medical Claims Examiner

Job title: Part-Time Medical Claims Examiner

Location: Remote

Job Type: Contractor/Part time

Pay range: $50/Hr

About Vasquez Platform

Vasquez is a healthcare technology platform designed to modernize insurance and payment operations. We connect telehealth vendors, care providers, and TPAs through real-time data interoperability - enabling instant access to eligibility, claims, and payment information. By automating the most manual parts of healthcare administration, Vasquez eliminates paperwork, reduces processing costs, and empowers organizations to deliver care more efficiently.

About the Role

We re looking for a part-time Medical Claims Examiner who can serve as a domain expert in designing and validating the claims adjudication module of our platform.

This isn t a traditional processing role it s a strategic, high-impact opportunity to help define how automated claims adjudication, denials, and workflows should function in a next-generation SaaS product.

You ll work directly with our product and engineering teams to design logic, rules, and exception flows that mirror real-world payer operations.

Responsibilities

• Define, document, and validate end-to-end health insurance claims workflows (837 adjudication 835).
• Translate payer rules, edits, and policy logic into decision trees for automation.
• Identify and document common denial reasons, appeals flows, and exception handling.
• Validate claims logic against real regulatory and operational edge cases.
• Collaborate with developers to review, test, and refine system behavior.
• Provide subject matter expertise on claims data standards, EDI formats, and payer policies.
• Advise on audit trails, compliance, and fraud-detection touchpoints.

Key Skills & Experience

• 7+ years in medical claims examination, adjudication, or TPA operations.
• Deep understanding of CPT, ICD-10, HCPCS, and NCCI edits.
• Hands-on familiarity with HIPAA 5010 EDI standards (837/835).
• Proven knowledge of Medicare, Medicaid, and commercial payer differences.
• Strong grasp of denials, appeals, and grievance workflows.
• Experience with claims systems (e.g., Facets, QNXT, HealthEdge, VBA, etc.).
• Ability to map workflows and translate rules into structured logic.
• Excellent communication able to articulate claim rules to technical teams.

Work Setup

• Hours: 5 10 hours/week (flexible schedule)
• Employment Type: C2C (Contract)
• Work Model: 100% Remote (WFH)

Engagement: Ongoing collaboration