Claims Specialist

Job Summary:

• The Claims Specialist, under the direction of the Supervisor (with guidance from a Team Lead), is responsible for processing medical claims received from patients and/or HCPs across a broad product suite.
• An individual in this role is expected to meet or exceed productivity and quality standards.
• Associates possess a solid understanding of department processes, products, and operational tools/systems.
• This position utilizes client and 3rd party systems to process claims and respond to inquiries from patients, physicians, pharmacies, and clients.
• The Associate may be assigned additional responsibilities by the Supervisor.

Duties and Responsibilities:

• Verifies the accuracy and completeness of claim forms and attachments, such as EOBs, EOPs, SPPs, and pharmacy receipts. Information is entered into adjudication systems as required.
• Claims are paid or rejected based upon system adjudication and/or application of business rules external to the systems.
• Consults with Team Lead or Supervisor for complex claims or clarification of business rules.
• Obtains missing information by calling or writing customers using standard scripts or form letters.
• Based on volume, may also process claims and/or may answer phones.
• Refers requests for escalation as needed and engages other internal areas such as Program Management, IT and other Contact Center teams to resolve issues.
• Provides input and feedback to Supervisor, Quality Management and Training (among others) to improve processes, procedures, and training.
• Other projects and tasks as assigned.

Qualifications:

• 1+ years in a health care or case management setting.
• Experience working in pharmacy benefits, health care insurance, and/or medical billing a must.
• Health care or pharmaceutical experience, particularly in a medical claims processing, billing provider or insurance environment.
• Knowledge of EOB and EOP statements.
• Prior experience in a high-volume processing setting (i.e., doctor’s office, claims processing department, etc.) a plus.
• Will be trained to support programs, clients and/or job functions as appropriate.
• Experience with Third-Party systems (SelectRx, Pro-Care, FSV) (preferred).
• Fluent in English/Spanish (a plus).
• Knowledge of Medical Claims processing/billing coding.

Skills:

• Communication skills: Uses writing effectively to create documents, uses correct spelling, grammar, and punctuation; Ability to convey written and verbal information in easy-to-understand language.
• Customer Focus: High level of empathy and emotional intelligence; Focuses on opportunity to service patients with a high level of empathy.
• Detail Oriented: Achieves thoroughness and accuracy when accomplishing a task.
• Adaptability: Adapts to a variety of situations easily and effectively navigates situations.
• Problem Solve: Thinks critically, and problem-solves issues to resolution.