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Job Requirements of Claims Specialist:
-
Employment Type:
Contractor
-
Location:
Pittsburgh, PA (Onsite)
Do you meet the requirements for this job?
Claims Specialist
Careers Integrated Resources Inc
Pittsburgh, PA (Onsite)
Contractor
Job Title: Claims Specialist
Job Location: Pittsburgh, PA
Job Duration: 3-4 Months (possibility of extension)
Job Location: Pittsburgh, PA
Job Duration: 3-4 Months (possibility of extension)
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.
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