Join Community Medical Group Community Medical Group is seeking a detail-oriented, analytical, and results-driven Medical Claims Specialist to join our team. As a Contestation Specialist, you will play a critical role in identifying and recovering revenue opportunities by reviewing medical and pharmacy claims, eligibility data, and supporting documentation. This position works closely with Health Plans, Network & Contracting teams, and internal stakeholders to manage contestation activities, monitor recoveries, analyze trends, and ensure compliance with contractual and regulatory requirements. This is an excellent opportunity for a healthcare analytics professional who enjoys problem-solving, financial analysis, and driving measurable outcomes. Benefits Eligible employees receive a comprehensive benefits package that includes: • 17 days of paid time off • 11 paid holidays and one floating holiday • Medical, dental, and vision coverage through UnitedHealthcare • 401(k) retirement plan with company match • Company-paid life insurance • Opportunities for professional growth Key Responsibilities • Review medical and pharmacy claims, eligibility files, and clinical documentation to identify contestation opportunities • Develop, maintain, and improve contestation policies and procedures • Monitor and track contestable claims on a weekly and monthly basis • Establish and maintain strong working relationships with Health Plans and payer representatives • Submit contestation requests and supporting documentation within established filing deadlines and contractual requirements • Collaborate with the Network & Contracting team to evaluate claims trends and recommend process improvements • Report on open contestation cases, recoveries, aging reports, trends, and financial impact • Create and maintain tracking tools, dashboards, and reporting mechanisms to monitor contestation performance • Analyze complex healthcare claims, pharmacy, eligibility, utilization, and reimbursement data • Identify trends and provide recommendations based on data analysis and findings • Maintain organized records of contestation submissions, supporting evidence, correspondence, and payment outcomes • Ensure compliance with Health Plan requirements, contractual obligations, regulatory guidelines, and internal policies • Support revenue recovery initiatives and process improvement efforts • Perform additional duties as assigned Qualifications • Bachelor's degree in Business, Finance, Computer Science, Engineering, Economics, or a related field preferred • 3-5 years of experience in healthcare claims analytics, payer operations, revenue recovery, or related healthcare functions required • Experience working with health plans, provider organizations, or value-based care environments preferred • Knowledge of healthcare reimbursement methodologies including DRGs, Revenue Codes, CPT Codes, HCPCS Codes, and bundled payments • Strong understanding of healthcare claims processing, eligibility, and reimbursement cycles • Knowledge of institutional and professional billing and various sites of care • Advanced proficiency in Microsoft Excel required • Experience with Power BI, Tableau, and/or Microsoft SQL preferred • Certified Subrogation Recovery Professional (CSRP) certification preferred • Strong analytical, financial, and problem-solving skills • Exceptional attention to detail and accuracy • Excellent written and verbal communication abilities • Ability to manage multiple priorities in a fast-paced environment • Strong project management and organizational skills • Ability to work independently while collaborating effectively across departments • Bilingual English and Spanish preferred Join Our Team Join a team dedicated to improving healthcare outcomes through operational excellence and financial stewardship. At Community Medical Group, you'll have the opportunity to make a meaningful impact by helping maximize revenue recovery, strengthen payer relationships, and support the continued delivery of high-quality care to the communities we serve.