Medical Claims Specialist

Job Description

Job Description

Job description:

Job Title: Medical Claims Specialist

Location: Minneapolis, MN (Hybrid – 2 Days/Week Onsite)

Employment Type:Contract-to-Hire

Job Summary

Seeking an experienced Critical Illness Claims Analyst to interpret policy language, review complex medical documentation, and adjudicate critical illness insurance claims accurately and efficiently. The ideal candidate will provide exceptional customer service while ensuring compliance with regulatory requirements and internal standards.

Key Responsibilities

• Analyze, investigate, and process complex Critical Illness claims accurately and timely.
• Determine claim approvals, denials, or requests for additional information based on policy provisions.
• Review medical records and clinical documentation to validate eligibility and benefit conditions.
• Communicate claim decisions clearly to customers through written correspondence and phone interactions.
• Handle sensitive customer situations with empathy and effective de-escalation techniques.
• Manage assigned work queues and meet established service level agreements (SLAs).
• Participate in root cause analysis and continuous process improvement initiatives.
• Collaborate with internal teams and cross-functional departments to resolve customer issues.
• Maintain compliance with company policies, regulatory requirements, and documentation standards.
• Support additional projects and duties as assigned.

Required Qualifications

• Experience processing insurance claims, preferably Critical Illness or Voluntary Benefits claims.
• Strong medical terminology and medical record review skills.
• Ability to interpret diagnoses, clinical evidence, and policy language to determine benefit eligibility.
• Experience handling complex claims and customer communications.
• Excellent analytical, critical thinking, and problem-solving abilities.
• Strong written and verbal communication skills.
• Ability to prioritize workloads and manage multiple tasks effectively.
• Advanced proficiency in claims processing systems and navigating multiple applications simultaneously.
• Strong knowledge of Microsoft Excel, Word, and Outlook.
• Ability to work independently with minimal supervision while maintaining high-quality standards.

Preferred Qualifications

• Voluntary Critical Illness Insurance claims experience.
• Complex medical review and adjudication experience.
• Background in insurance, healthcare, disability, or benefits administration.

Experience:

• Medical coding: 1 year (Required)
• Medical Claims: 4 years (Required)
• Medical Insurance: 2 years (Required)

Work Location: Hybrid remote in Minneapolis, MN 55401

Incorporated in 1991, Real Soft Inc. (RSI) is a US-based global software solutions company, a pioneer in providing professional services and delivering business solutions. Our persistent focus has been on forging strong relationships through service excellence and cost containment for customers.
Address:
125 Village Blvd
Forrestal Village, Suite 200
Princeton, NJ 08540

Company Description

Incorporated in 1991, Real Soft Inc. (RSI) is a US-based global software solutions company, a pioneer in providing professional services and delivering business solutions. Our persistent focus has been on forging strong relationships through service excellence and cost containment for customers.\r\nAddress:\r\n125 Village Blvd\r\nForrestal Village, Suite 200\r\nPrinceton, NJ 08540