Elite Technical Services is partnering with a premier healthcare insurance organization to secure specialized Medical Claims Processors for their Inter-Plan Teleprocessing System (ITS) Home Medicare Advantage team. This track focuses specifically on the ITS Home workflow, managing cross-border claims processing for local members who received care outside of their home network.

This specialized position is ideal for processors with a deep understanding of the BlueCard- ecosystem who excel at applying local Medicare Advantage guidelines to electronic inter-plan data transmissions.

Key Responsibilities:
- Review, audit, and finalize complex medical claims routed via the electronic Inter-Plan Teleprocessing System (ITS).
- Focus strictly on the ITS Home perspective, validating and adjudicating out-of-state claims against the member's localized Medicare Advantage (MA) benefit rules and plan guidelines.
- Navigate the Facets G6/360 core software platform to reconcile incoming electronic claims data with patient enrollment, local accumulators, and coverage limits.
- Troubleshoot and resolve specialized system pends, cross-plan billing discrepancies, or routing bottlenecks to ensure seamless inter-plan provider reimbursement.
- Collaborate closely with quality and compliance guidelines to maintain razor-sharp data accuracy.
- Meet or exceed rigid daily processing quotas and procedural accuracy metrics established by the department.

Required Skills

- HS Diploma is required with 3+ years of Healthcare Claims Processing experience / medical claims processing and adjudication experience is strictly required.
- Prior experience with the ITS Home workflow and BlueCard- program parameters is required (Note: This role focuses on Home plan adjudication, not ITS Host processing).
- One or both is required:
(1) Experience processing Medicare Advantage (MA) claims
(2) Experience utilizing the Facets core claims platform (specifically Facets G6 or the web-based Facets 360 interface)

- Exceptional analytical skills with the ability to cross-reference multi-layered plan benefits across out-of-network provider structures.
- Strong productivity mindset, capable of managing high-volume claims lines without sacrificing data quality.