Claim Specialist - 5595

Job Description

Are you an experienced medical claims professional who enjoys solving complex problems, researching payment issues, and making sure claims are processed correctly?

We're looking for a Claims Specialist II to join a healthcare claims operations team. In this role, you'll investigate and resolve medical claims issues, process adjustments, research Coordination of Benefits (COB), correct payment discrepancies, and help recover overpayments.

If you have at least 2 years of hands-on medical claims processing experience and enjoy digging into the details to figure out what happened and how to fix it, we'd love to hear from you.

Medical claims processing experience is REQUIRED. COB experience is highly preferred.

What You'll Do

You'll take ownership of medical claims from research through resolution, helping ensure claims are processed accurately, efficiently, and according to established benefits and reimbursement guidelines.

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• Review, research, and process medical claims.
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• Investigate claims edits, denial codes, processing codes, and payment discrepancies.
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• Adjust and reprocess previously paid claims when necessary.
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• Recalculate benefits based on plan and provider reimbursement requirements.
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• Research Coordination of Benefits (COB) and determine primary versus secondary insurance coverage.
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• Apply COB rules involving subscriber status, effective dates, plan types, Medicare coordination, and other coverage factors.
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• Research and correct inaccurate COB and coverage records.
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• Communicate with members, providers, and other insurance carriers to verify coverage and resolve claims issues.
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• Identify overpayments and initiate refund or recovery processes.
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• Review previously processed claims to identify additional recovery opportunities.
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• Request and review medical records when needed to support claims research.
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• Review quality audit findings and complete required corrections within established timelines.
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• Maintain accurate and complete claims documentation.
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• Partner with Provider Services, Enrollment & Billing, Legal, Internal Audit, IT, and other departments to resolve complex issues.
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• Assist with special projects, audits, system issues, training, implementations, and process improvements as needed.
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What We're Looking For

Required Qualifications

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• High School Diploma or equivalent.
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• Minimum 2 years of hands-on medical claims processing experience .
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• Strong understanding of healthcare claims processing and adjudication.
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• Experience researching and resolving claims discrepancies.
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• Knowledge of claims edits, denial codes, benefits, and payment information.
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• Experience reviewing and correcting previously processed claims.
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• Strong analytical, investigative, and problem-solving skills.
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• Excellent attention to detail and documentation accuracy.
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• Strong written and verbal communication skills.
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• Ability to prioritize multiple claims and assignments in a fast-paced environment.
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• Comfortable navigating claims systems and standard computer applications.
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What Will Make You Stand Out

We're especially interested in candidates with experience in:

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• Coordination of Benefits (COB)
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• Primary and secondary payer determination
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• Medicare coordination and primacy
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• Medicare Secondary Payer (MSP) concepts
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• Claims adjustments and reprocessing
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• Overpayment identification and recovery
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• Refund processing
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• Complex or escalated claims research
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• Provider reimbursement
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• Eligibility and benefits research
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• Claims quality audits
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• Commercial, Medicare, or Medicaid claims
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• Health insurance payer environments
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Why You'll Love This Opportunity

This isn't just a claims processing role. You'll have the opportunity to use your analytical and investigative skills to understand why claims processed the way they did and determine what needs to happen next.

You'll work with claims, coverage, benefits, COB, payment discrepancies, and recovery efforts while partnering with teams across the organization.

For someone who enjoys researching complex claims, solving problems, and getting things right , this is an opportunity to make a direct impact on claims accuracy, customer satisfaction, and overall healthcare operations.