Claims Specialist II

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

📋 Description

• Conduct data analysis, auditing, and finalize adjudication outcomes for claims selected for pre-payment review.

• Execute post-payment reviews of claim adjudication outcomes through research, utilizing knowledge of CMS, NC Medicaid, and Trillium billing guidelines and policies.

• Provide assistance to providers via phone or email concerning claims processing inquiries.

• Engage with internal and external stakeholders to enable efficient claims resolution.

• Evaluate and audit claims adjudication outcomes for precision in alignment with NC Medicaid guidelines.

• Review and audit claim attachments and medical documentation necessary for claims adjudication.

• Analyze, audit, and take appropriate measures on claims that are delayed due to rejection errors.

• Identify adjudication errors, provider billing mistakes, and the need for technical support.

• Review and implement departmental training, published coverage policies, and NCDHHS documents.

• Deliver training, education, and technical support to provider agencies regarding claim submission protocols, denial management, system utilization, and updates.

• Identify and report suspected system issues or concerns to the immediate supervisor.

⛳️ Requirements

• High School Diploma/GED along with two (2) years of experience in claims processing, billing, or medical coding; OR an equivalent combination of education and experience.

• A valid driver's license is required.

• Residency in North Carolina is mandatory.

• Ability to travel within the designated catchment area as necessary.

• An Associate's degree in Healthcare Administration, Business, or a Human Services field is preferred.

• Experience with hospital claims and related knowledge is preferred.

• Prior experience in physical health claims processing or medical coding is preferred.

• Familiarity with Managed Care billing software is preferred.

• Certifications such as Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS), or similar credentials are preferred.

• All candidates must successfully pass a drug test as a condition of employment.

• Resume must detail employer name, dates of service, average weekly hours worked, key job responsibilities, educational background, and licensure/certification information where applicable.

🏝️ Benefits

• Competitive benefits package.

• Work-from-home options available for most positions.

• Flexible work schedules with management approval for certain roles.

• Health Insurance with no premium for employee coverage.

• Flexible Spending Accounts.

• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year.

• NC Local Government Retirement Pension (defined-benefit plan).

• 401k plan with 5% employer match and immediate vesting.

• Qualifying employer for Public Service Loan Forgiveness (PSLF).

• Quarterly stipend for remote work supplies.