Claims specialist
Actively Hiring - Claims Specialist
Job Description The Claims Specialist will support department operations related to provider communication, pended claim review, reporting, auditing, and oversight activities to ensure compliance with all applicable State, Federal, and contractual guidelines. Responsibilities- Review and investigate claims to be adjudicated by the Third Party Administrator, including the application of contractual provisions in accordance with provider contracts and authorizations.
- Compile claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner.
- Investigate suspense conditions to determine if system or procedural changes would enhance claim workflow.
- Communicate and follow up with various internal and external sources, including providers, members, attorneys, regulatory agencies, and other carriers on any claim-related matters.
- Analyze patient and medical information to identify Coordination of Benefits, Worker's Compensation, No-Fault, and Subrogation conditions.
- Experience in claims processing and medical billing.
- Proficiency in Microsoft Office Suite, including Excel, Word, and PowerPoint.
- Experience using a claims processing system or comparable database software.
- Strong communication skills for interacting with providers, members, and regulatory agencies.
- Certified Professional Coder (a plus).
- Experience within healthcare or managed care setting preferred.
- Knowledge of MLTC/Medicaid/Medicaid benefits.
- Understanding of Utilization Authorizations.
- Familiarity with CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS.
- Medical, dental & vision
- Critical Illness, Accident, and Hospital
- 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)
- Short and long-term disability
- Health Spending Account (HSA)
- Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)
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