Claims Specialist

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

📋 Description

• Resolve medical claims that are not automatically processed by the claims management system.

• Investigate claims and communicate to gather necessary information.

• Input data into the claims system.

• Review and interpret contract benefits.

• Conduct edit and audit resolutions.

• Determine eligibility for benefits.

• Identify and research processing issues using systems and manuals.

• Route claims to appropriate areas.

• Consult with internal staff and medical providers.

• Generate correspondence as needed.

• Complete forms to acquire necessary information.

• Undergo initial training, on-the-job training, and continuing education.

• Access relevant computer systems and screens to ensure accurate claims processing.

• Stay updated with changing processing procedures, benefits, and system modifications.

• Meet corporate and national (MTM) standards for productivity and quality.

• Utilize corporate and professional manuals and guidebooks, including processing manuals and ICD, CPT, and HCPS codebooks.

• Perform additional duties as assigned.

⛳️ Requirements

• High School diploma or equivalent.

• A minimum of two (2) years of college coursework (48 semester hours) or equivalent certification with a focus in anatomy, medical terminology, math, biology, or a related field, OR at least one (1) year of relevant office experience such as claims processing, health insurance, or medical office.

• Must successfully pass the company proficiency test: Claims Assessment.

• Strong oral and written communication skills.

• Excellent interpersonal skills.

• Good judgment and decision-making abilities.

• Detail-oriented with a focus on accuracy.

• Ability to work collaboratively in a team environment.

• Dependable and reliable.

• Must ensure the security and confidentiality of records and information.

• Must comply with segregation of duties guidelines as outlined in the Administrative Manual.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional development and growth.

• Supportive work environment with a focus on teamwork.