Senior Claims Specialist

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

📋 Description

• Conduct data analysis and auditing, finalizing adjudication results for claims selected for both pre-payment and post-payment reviews, utilizing knowledge of billing guidelines and policies set by CMS, NC Medicaid, and Trillium procedures.

• Support providers via phone or email with inquiries regarding claims processing, while also engaging with internal and external stakeholders to promote effective claims resolution.

• Evaluate and audit claims adjudication results to verify that claims were submitted and processed correctly in accordance with NC Medicaid guidelines.

• Review and assess claim attachments and medical documentation essential for the proper adjudication of claims.

• Detect adjudication discrepancies, provider billing mistakes, and the necessity for technical support.

• Ensure that the claims system and manual processes are aligned with required actions by examining and implementing information from departmental training, published coverage policies, and other NCDHHS documentation.

• Deliver training, education, and technical assistance to provider agencies based on findings from analysis or audits related to basic claim submission protocols, denial management, and system usage updates.

⛳️ Requirements

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

• A valid driver’s license is required.

• Candidates must reside within North Carolina.

• Ability to travel within the catchment area as needed.

• Preferred: An Associate’s degree in Healthcare Administration, Business, or a Human Services field (such as Psychology or Social Work).

• Experience and knowledge related to hospital claims.

• Familiarity with the processing of physical health claims or medical coding.

• Experience 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 certifications are preferred.

🏝️ Benefits

• 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 with 5% employer match and immediate vesting.

• Public Service Loan Forgiveness (PSLF) qualifying employer.

• Quarterly stipend for remote work supplies.