We are a North American medical insurance provider seeking an experienced Medical Insurance Claims Specialist to support the review and administration of health insurance claims for a defined portfolio of insured individuals and business clients.
This role is responsible for independently reviewing, approving, denying, and submitting medical claims in accordance with insurance policy terms, coverage guidelines, and applicable regulations. You will manage a consistent caseload and act as the primary claims point of contact for your assigned accounts, ensuring accurate, timely, and well-documented claim decisions.
- Review medical insurance claims for completeness, accuracy, and policy compliance
- Approve or deny claims based on benefit structures, coverage limits, and medical necessity
- Submit claims on behalf of insured individuals and employer groups when required
- Manage a defined portfolio of individual and business accounts
- Interpret policy documents, benefit schedules, exclusions, and coverage rules
- Request, assess, and document supporting materials such as invoices, medical records, and provider documentation
- Communicate claim outcomes clearly and professionally with internal teams and clients
- Ensure all claim decisions align with North American regulatory and compliance standards
- Maintain detailed, audit-ready claim files and documentation
- Demonstrated experience in medical insurance claims processing or adjudication
- Strong working knowledge of health insurance policies, benefits, and exclusions
- Experience with North American health insurance providers (Canada and/or United States)
- Proven ability to independently approve and deny claims using policy guidelines
- Excellent attention to detail and sound judgment in claims decision-making
- Strong written communication skills in English
- Ability to manage a steady claims workload and meet turnaround expectations
- Experience with group health plans or employer-sponsored insurance
- Familiarity with claims management systems or medical billing platforms
- Background in benefits administration, underwriting support, or healthcare billing
- Knowledge of HIPAA, PHIPA, or comparable health data privacy frameworks
- Remote, freelance contract via Upwork
- Ongoing work with a consistent volume of claims
- Assigned portfolio of insured individuals and business clients
- Flat monthly health insurance stipend provided for the duration of the contract, intended to support the purchase of independent health insurance coverage
- Opportunity for long-term collaboration based on performance and reliability
Please include the following in your application:
- A brief summary of your medical claims experience
- The types of insurance providers you have worked with (U.S., Canada, or both)
- Your experience approving and denying medical claims
- Any relevant certifications, training, or compliance experience