Claims Research Specialist

This is a fully remote position, open to applicants in California.

📋 Description

• Conduct research and resolve intricate claims processing, billing, provider claims adjudication, and payment dispute matters.

• Promptly rectify errors to enhance provider and customer satisfaction.

• Address inquiries from providers and internal departments through phone, mail, or fax.

• Investigate and resolve provider payment disputes and appeals.

• Analyze claim status and clarify contract status, financial risk, and payment methodologies.

• Educate providers on contracts and inform them of any errors that arise.

• Monitor and analyze issues, recommending enhancements to contract terms, contract setup, and claims adjudication policies.

• Facilitate one-time rate negotiations as referred by the claims department.

• Document negotiation outcomes and submit claims for prompt payment.

• Interact with internal departments and external customers via telephone, email, and written correspondence.

• Cultivate professional relationships with internal departments, vendors, providers, employers, brokers, and other clientele.

• Engage in special projects, work groups, proposals, audits, and provide backup support.

• Aid in the preparation of reinsurance filings.

• Maintain organized workspaces, files, tools, resources, and reference materials.

• Utilize plan policies, benefit agreements, regulations, provider manuals, fee schedules, databases, contracts, and applications to meet departmental needs.

⛳️ Requirements

• A minimum of 2 years of experience in a health plan or other healthcare environment, including claims processing, customer service call center, provider contracting and relations, and medical billing.

• Proven experience in resolving issues in high-pressure and stressful situations.

• Proficient with electronic mail, word processing, spreadsheets, and database applications.

• Candidates must reside in California for this remote role.

• Comprehensive understanding of managed care principles, models, and reimbursement methodologies.

• Acquainted with DMHC and DHS regulations.

• Knowledge of CPT and ICD-10-CM diagnosis and procedure codes, as well as other billing guidelines.

• High School Diploma or Equivalent is preferred.

• Experience with Managed Care applications is preferred.

• Certifications such as CPC-H, CPC-P, CPC, and CCS are preferred.

• Certification in medical terminology and/or medical billing/coding is preferred.

🏝️ Benefits

• Primarily remote work / work from home.

• Full-time employment.

• Day shift schedule.

• No on-call requirement.

• Equal opportunity/affirmative action employment.