Claims WFH - Health Insurance

Job Description

Job Description

HIRING NOW – WFH CLAIMS SPECIALIST

We are seeking a detail-oriented and experienced Claims Specialist to join a leader in the health insurance industry. In this role, you will be responsible for processing, adjusting, and updating moderate to complex claims payments and payment errors. You will act as a key point of contact for resolving inquiries from customer service professionals, subscribers, providers, physicians, and other insurance carriers, ensuring all claims are handled accurately and efficiently.

Position Details

• Schedule: Monday – Friday, 8:00 AM – 5:00 PM EST.
• Location: 100% Remote (Available to candidates residing in 28 approved states)
• Compensation: $21 - $23/hour (based on years of experience).

Key Responsibilities

• Process, adjust, and update various moderate to complex claims payments for any business segment and provider type. Determine suspended claim resolution methods by reviewing benefit eligibility and claims history.
• Process Medicare claims, review DTPs, and utilize Facets for Medicare Advantage and Medicare Supplement claims.
• Meet or exceed established quality and performance standards. Daily production goals are based on an hourly target of 7 claim pends, 7 COB pends, and 4 CSI/ADJ.
• Respond promptly and accurately to inquiries from internal and external stakeholders. Coordinate with other insurance carriers and Medicare to determine payment liability.
• Escalate claims requiring specialized resolution to subject matter experts (SMEs). Review claims for possible fraud and abuse, referring them to the Special Investigations Unit when necessary.
• Identify and document system issues, recommending potential solutions to technical staff. Use your knowledge of claims to drive efficiency, production gains, and share best practices.

Qualifications & Requirements

• High School Diploma or GED
• 3+ years of experience processing Insurance Claims.
• Proven experience processing Medicare Advantage and Medicare Supplement claims.
• Experience running and navigating Facets, as well as reviewing DTPs.
• Strong analytical skills, excellent communication, and the ability to maintain high accuracy in a production-driven environment.

TO APPLY: Email Resume to: View email address on ziprecruiter.com

If this job is not for you, feel free to refer a friend.

Skills

• Claims
• Claims Processing
• Insurance
• health insurance
• claims processor
• medicare
• COB
• facets
• TriZetto
• claims analyst

Randstad is a world leader in matching great people with great companies. Our experienced agents will listen carefully to your employment needs and then work diligently to match your skills and qualifications to the right job and company. Whether you're looking for temporary, temporary-to-permanent or permanent opportunities, no one works harder for you than Randstad.

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact View email address on ziprecruiter.com.

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.