Claims Specialist

Overview:

The Claims Specialist, under the direction of the Supervisor (with guidance from a Team Lead), is responsible for processing medical claims received from patients and/or HCPs across a broad product suite. An individual in this role is expected to meet or exceed productivity and quality standards. Associates possess a solid understanding of department processes, products, and operational tools/systems. This position utilizes ConnectiveRx and 3rd party systems to process claims and respond to inquiries from patients, physicians, pharmacies, and clients. The Associate may be assigned additional responsibilities by the Supervisor.

Responsibilities:

Verifies the accuracy and completeness of claim forms and attachments, such as EOBs, EOPs, SPPs, and pharmacy receipts. Information is entered into adjudication systems as required. Claims are paid or rejected based upon system adjudication and/or application of business rules external to the systems. Consult with the Team Lead or Supervisor for complex claims or clarification of business rules. Obtains missing information by calling or writing customers using standard scripts or form letters. Based on volume, may also process claims and/or answer phones

Refers to requests for escalation as needed and engages other internal areas such as Program Management, IT, and other Contact Center teams to resolve issues.

Provide input and feedback to the Supervisor, Quality Management, and Training (among others) to improve processes, procedures, and training.

Other projects and tasks as assigned

Qualifications:

High School or GED required

1+ years in a health care or case management setting

Experience working in pharmacy benefits, health care insurance, and/or medical billing a must

Health care or pharmaceutical experience, particularly in a medical claims processing, billing provider, or insurance environment

Knowledge of EOB and EOP statements

Prior experience in a high-volume processing setting (i.e., doctor’s office, claims processing department, etc.) a plus.

Will be trained to support programs, clients, and/or job functions as appropriate

Experience with Third-Party systems (SelectRx, Pro-Care, FSV) (preferred)

Fluent in English/Spanish (a plus).

Knowledge of Medical Claims processing/billing coding

Communication skills: Uses writing effectively to create documents, uses correct spelling, grammar, and punctuation; Ability to convey written and verbal information in easy-to-understand language.

Customer Focus: High level of empathy and emotional intelligence; Focuses on the opportunity to service patients with a high level of empathy

Detail Oriented: Achieves thoroughness and accuracy when accomplishing a task

Adaptability: Adapts to a variety of situations easily and effectively navigates situations

Problem Solve; Thinks critically, and problem-solves issues to resolution

Permanent