Policy Support Specialist

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Investigate member medical records to address claims or service requests that are pending due to clinical edits across all lines of business.

• Assess medical policies to make informed decisions regarding claims processing or clinical review processes.

• Oversee the clinical review and appeal procedures, which includes organizing cases for clinical evaluation and obtaining additional information from members and providers.

• Analyze clinical determinations and initiate necessary claim adjustments and service request closures, which includes writing manual correspondence.

• Evaluate and establish pricing for clinical claims in line with negotiated pricing agreements.

• Review and revise Coordination of Benefit (COB) files and provide updates to provider files as needed.

• Detect technical issues and escalate them to the relevant department for resolution.

• Address incoming telephone inquiries as required.

• Carry out additional tasks as directed by management.

⛳️ Requirements

• A minimum of a High School Diploma or GED equivalent is required.

• At least three (3) years of experience in health care claims processing, including the research and investigation of customer inquiries.

• A minimum of two (2) years of experience with medical terminology, billing, and coding is necessary.

• Familiarity with COB and Horizon medical policies is preferred.

• Knowledge of all lines of business is preferred.

• Strong analytical and critical thinking abilities are preferred.

• Excellent organizational and communication skills are essential.

• Candidates must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement