Claims Specialist II

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

📋 Description

• Conduct data analysis and auditing for claims earmarked for pre-payment review

• Evaluate claims adjudication outcomes through research and understanding of CMS, NC Medicaid, and Trillium billing guidelines and policies

• Examine and audit claim attachments and medical documentation

• Implement appropriate measures for claims that are delayed due to rejection errors

• Detect adjudication mistakes, provider billing inaccuracies, and areas needing technical assistance

• Review and incorporate departmental training, published coverage policies, and NCDHHS documentation

• Offer training, education, and technical support to provider agencies regarding claim submission protocols, denial management, system navigation, and updates

• Assist providers via phone or email with inquiries related to claims processing

• Liaise with internal and external stakeholders to ensure efficient resolution of claims

• Report any suspected system issues or concerns to the designated supervisor

⛳️ Requirements

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

• Valid driver’s license

• Must be a resident of North Carolina

• Ability to travel within the catchment area as necessary

• Legally authorized to work in the United States without the need for future sponsorship

• Preferred: Associate’s degree in Healthcare Administration, Business, or a Human Services discipline

• Experience with hospital claims and relevant knowledge is preferred

• Background 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 are preferred

• Must successfully pass a drug test as a condition of employment

🏝️ Benefits

• Competitive benefits

• 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 the first year

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

• 401k with a 5% employer match and immediate vesting

• Employer qualifies for Public Service Loan Forgiveness (PSLF)

• Quarterly stipend for remote work supplies

• Opportunities for professional growth

• Collaborative, mission-driven work environment

• Diverse, inclusive culture