Claims Specialist

The Claims Specialist is primarily responsible for processing Medicare and Medicaid subrogation claims received from external vendors in compliance with Medicare Secondary Payer (MSP) laws and internal client configurations. This role also supports internal teams by managing JIRA requests related to claims adjudication issues. The Claims Specialist serves as a Subject Matter Expert (SME) for claims processing, system testing, audits, and enhancements. This position requires on-site attendance five (5) days per week. Key ResponsibilitiesMedicare / Medicaid Subrogation Serve as the primary point of contact for all Medicare and Medicaid-related inquiries Communicate with external vendors regarding subrogation processes and requirements Receive, log, and process Medicare and Medicaid subrogation claims Review and respond accurately and timely to all demand letters in accordance with regulatory guidelines The Claims Specialist is primarily responsible for processing Medicare and Medicaid subrogation claims received from external vendors in compliance with Medicare Secondary Payer (MSP) laws and internal client configurations. This role also supports internal teams by managing JIRA requests related to claims adjudication issues. The Claims Specialist serves as a Subject Matter Expert (SME) for claims processing, system testing, audits, and enhancements. This position requires on-site attendance five (5) days per week. Key ResponsibilitiesMedicare / Medicaid Subrogation Serve as the primary point of contact for all Medicare and Medicaid-related inquiries Communicate with external vendors regarding subrogation processes and requirements Receive, log, and process Medicare and Medicaid subrogation claims Review and respond accurately and timely to all demand letters in accordance with regulatory guidelines Cross-Functional Collaboration Manage the Claims Support email inbox and JIRA queue, ensuring timely and appropriate responses Address complex or escalated claims issues and partner with Client Services and Member Services to ensure high levels of customer service Provide troubleshooting support for claims adjudication issues across departments Client Implementation and System Testing Lead claims-related testing components for new client implementations Coordinate and perform plan design testing for new clients, new plans, and plan changes Collaborate with IT, Implementation, and Client Success teams to resolve system inconsistencies and validate claims adjudication accuracy Serve as the claims processing SME during audits, enhancement meetings, and system change testing Conduct regression testing following system updates or corrections Perform post-implementation monitoring of claims to ensure accuracy and compliance Claims Quality Review Perform weekly ESI audit reversals Monitor and analyze the weekly Unbalanced Claims report Identify trends, root causes, and opportunities for process improvement QualificationsRequired 3+ years of experience in claims processing or a related insurance field Strong understanding of claims processing procedures, benefits administration, coordination of benefits (COB), and reimbursement methodologies Proficiency in Microsoft Excel Excellent organizational, analytical, and problem-solving skills Ability to interpret policy documents, benefit plans, Explanation of Benefits (EOBs), and regulatory guidelines Ability to work effectively in a fast-paced environment with shifting priorities Ability to work on-site five (5) days per week Preferred Experience interpreting claims data to support decision-making Strong knowledge of HMS rules and regulations Experience with Medicare/Medicaid subrogation claim processing Experience with plan design configuration and benefits setup Familiarity with Medicare/Medicaid regulations, subrogation concepts, and state/federal insurance requirements Benecard Services, LLC Benecard Services, LLC has been administering carve-out, fixed rate insured prescription drug benefit programs since 1990. Benecard is a full service, in-house prescription benefit administrator that includes mail and specialty drug dispensing. We are a premiere nationwide Prescription Benefit Administrator headquartered in Lawrenceville, New Jersey. Website: BeneCard PBF BeneCard PBF provides self-funded prescription benefit program administration with a personalized approach through focused, clinical expertise. Our business model operates on a customized claim processing system offering unlimited capability and flexibility to respond to client needs in an evolving marketplace. Advanced clinical programs and advanced technology provide the framework to maximize the use of all data elements available. This allows BeneCard PBF to filter the information, focus on clinical opportunities and facilitate interaction between the physician, the pharmacist and the patient to effectively promote complete health care. Headquartered in Bonita Springs, Florida. Website: National Vision Administrators For over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health & Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey. Website: We are an Equal Opportunity employer. #J-18808-Ljbffr