Claims Specialist I

Role Description

The Claims Specialist resolves medical claims that are not automatically adjudicated by the claims processing system in a timely and accurate manner according to divisional standards of quality and productivity. Resolution may include additional investigation or communication in order to obtain necessary information to complete the claim. Outside issues such as peak filing season, systems down time, inclement weather, holidays, and absenteeism may directly affect the volume of work for each Specialist.

Qualifications

• High School diploma or equivalent.
• Minimum two (2) years' college coursework (48 semester hours) or other equivalent certification with an emphasis in anatomy, medical terminology, math, biology, or a related field.
• OR minimum one (1) year of related office experience such as claims processing, health insurance, or medical office.
• Must pass company proficiency test: Claims Assessment.

Requirements

• Oral & Written Communications
• Strong Interpersonal skills
• Sound Judgement
• Decision Making
• Detail-Oriented
• Teamwork
• Dependability
• Clinical Judgment
• Computer Work
• Critical Thinking
• Customer Service
• Evaluating Information
• Interpersonal Communication
• Oral Communications
• Organizing
• Process Information
• Reading Comprehension
• Researching
• Time Management

Responsibilities

• Claims Processing: Involves the actions required to pay or deny pended claims (those which did not auto-adjudicate), including:
  • Entering data into the system
  • Reviewing and interpreting contract benefits
  • Conducting edit and audit resolution
  • Determining benefit eligibility
  • Identifying and researching processing issues through systems and manuals
  • Routing claims to other areas
  • Consulting internal staff and medical providers
  • Generating correspondence
  • Completing forms to obtain necessary information
• Knowledge/Continuous Learning: Must undergo initial training, on-the-job training, and continuing education. Responsibilities include:
  • Demonstrating knowledge of and possessing the ability to access all relevant computer systems and screens to process claims accurately
  • Staying current with continually changing processing procedures, benefits, and system modifications
  • Meeting corporate and national (MTM) standards while maintaining acceptable performance levels based on established departmental standards for productivity and quality
  • Familiarity with corporate and professional manuals and guidebooks, including the company processing manual and ICD, CPT, and HCPS codebooks
• Other duties: As assigned

Certifications

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.