Claims Specialist II

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

📋 Description

• Accurately process claims edits and determine the primary responsibility for Coordination of Benefits (COB).

• Make adjustments to previously settled claims and initiate recovery processes for any overpaid claims.

• Analyze, investigate, and resolve cases with issues.

• Implement recovery processes and complete special projects as assigned.

• Review, research, and update claims, which includes recalculating benefits, editing claims, and managing refund requests.

• Maintain a thorough understanding of systems, applications, denial codes, edits, and processing codes to accurately handle both coordinated and non-coordinated claims.

• Request medical records as necessary.

• Communicate with both internal and external contacts to ensure accurate claim records are established.

• Review quality audits and correct or reroute them within a 48-hour timeframe.

• Research and ascertain the correct order of benefits and maintain accurate COB records.

• Notify the appropriate departments if Medicare incorrectly determines primacy.

• Review processed claims for payment consistency and optimize overpayment recovery.

• Recover funds from providers, subscribers, or beneficiaries in cases of overpayments.

• Assist with training, implementations, and documentation processes.

• Perform additional assigned duties and special projects as needed.

⛳️ Requirements

• A High School Diploma or equivalent is required.

• A minimum of 2 years of experience in medical claims processing is required.

• Experience in Coordination of Benefits (COB) processing is preferred.

• Possess strong analytical skills, including logical, systemic, and investigative thinking capabilities.

• Excellent oral and written communication skills are essential.

• Strong interpersonal skills are required.

• Proficient working knowledge of relevant PC software is necessary.

• Ability to effectively prioritize multiple streams of work.

• Capable of comprehending, documenting, calculating, visualizing, and analyzing data.

• No specific licenses or certifications are required.

• Must successfully complete pre-employment drug screening.

• Subject to background and pre-employment checks after receiving an offer.

• Residency in Louisiana or willingness to relocate is preferred.

🏝️ Benefits

• Access to resources that promote wellness and health.

• Opportunities for continued learning and skill enhancement.

• Potential for professional growth and development.

• A smoke- and tobacco-free workplace environment.

• Background and pre-employment drug screening after an offer is extended.

• Reasonable accommodations are available for individuals with disabilities.