Determination Adjudicator

What You’ll Do: Review medical records and supporting documentation submitted with medical sharing requests for completeness, accuracy, and in line with Zion Health Share Member Guidelines. Apply your knowledge of medical terminology, conditions, diagnostics, procedures, evidence-based treatments, and typical treatment timelines when reviewing requests. Research medical information and treatment standards when additional context is needed to make an informed determination. Collaborate with internal teams to gather clarification or additional documentation. Make consistent, well-supported determinations regarding eligibility for sharing or the need for additional information. Clearly document determinations and the rationale supporting each decision. Stay current on Member Guideline updates and relevant healthcare and treatment practices. Identify opportunities to improve or clarify Member Guidelines and provide recommendations when appropriate. Protect member information by maintaining strict confidentiality and following HIPAA and organizational requirements. Approach every determination with accuracy, consistency, and compassion for the member experience.

What We’re Looking For: Required Current professional certification or credential in a relevant healthcare field, such as Medical Assisting, Medical Billing, Medical Coding, or Healthcare Claims. Examples may include CMA, RMA, CCMA, CPC, CCS, or other recognized healthcare-related credentials. Strong understanding of medical terminology, healthcare processes, and common treatments for acute and chronic conditions. Strong analytical and critical-thinking skills with the ability to interpret detailed medical information and apply established guidelines. Excellent written and verbal communication skills. Exceptional attention to detail and the ability to make fair, consistent, and objective decisions. Ability to work efficiently in a fast-paced environment while managing multiple systems and priorities. Proficiency with Microsoft Office and comfort learning new software and CRM systems. Ability to type at least 45 WPM. Preferred Experience reviewing medical records, healthcare claims, medical bills, coding, or supporting medical documentation. Previous experience in healthcare, medical review, case management, claims adjudication, utilization review, or a health-sharing organization. Experience working within a CRM or case-management system. Spanish fluency is a plus and may qualify for additional compensation. Why You’ll Love Working at Zion Health Share We want our employees to feel supported both at work and outside of it. Our benefits and perks include: 13 paid holidays, including your birthday and a Personal Preference Day, plus paid time off. A comprehensive healthcare package including medical, dental, and vision coverage, an HSA with company contributions, supplemental benefits such as life and short-term disability coverage, a Zion Health Share membership, and a free Direct Primary Care (DPC) membership. A 401(k) with a 4% company match to help you invest in your future. Biweekly pay. Free onsite snacks and regular company lunches. Frequent team-building activities and opportunities to connect with coworkers. At Zion Health Share, our core values of transparency, simplicity, community, and compassion guide how we serve our members—and how we work with one another.