Claims Specialist

Job Description

STRATEGIC STAFFING SOLUTIONS HAS AN OPENING!

This is a Contract Opportunity with our company that MUST be worked on a W2 Only. No C2C eligibility for this position. Visa Sponsorship is Available! The details are below.

"Beware of scams. S3 never asks for money during its onboarding process."

Job Title: Claims Specialist
Remote Work
Contract Length: 5 Months

Job Ref #: 247717

The Claims Specialist will support claims operations by accurately processing claims edits, determining primacy for Coordination of Benefits, adjusting previously paid claims, and initiating procedures to recover funds on overpaid claims. This position will analyze, investigate, and resolve problem cases, execute recovery processes, and complete special projects while complying with applicable laws and regulations.

Required Qualifications

• High school diploma or equivalent
• At least 2 years of medical claims-processing experience
• Strong analytical ability, including logical, systemic, and investigative thinking
• Strong oral and written communication skills
• Strong human-relations skills
• Working knowledge of relevant PC software
• Ability to prioritize multiple streams of work effectively

Preferred Qualifications

• Coordination of Benefits processing experience
• Hands-on experience determining which insurance plan pays first when a member has multiple sources of coverage
• Experience identifying primary and secondary coverage
• Experience reviewing and updating claims based on COB rules
• Experience applying COB primacy rules, including subscriber status, effective dates, plan type, and Medicare coordination
• Experience communicating with members, providers, and other insurers to verify coverage information
• Experience correcting overpayments, initiating refunds or reprocessing claims, and maintaining accurate claim records
• Experience working within claims systems and following regulatory and compliance requirements, including HIPAA

Responsibilities

• Review, research, and update claims, including recalculating benefits on previously processed claims
• Process claims edits according to contractual benefits and provider-reimbursement rules
• Initiate refund requests when necessary
• Identify denial codes, edits, and processing codes associated with coordinated and non-coordinated claims
• Request medical records when required
• Communicate orally and in writing with internal and external contacts to establish accurate claims records
• Review quality audits for correction or routing within 48 hours of receipt
• Research and determine the correct order of benefits for payment by applicable plans
• Make necessary corrections to COB records
• Notify the appropriate departments when Medicare has determined primacy incorrectly
• Analyze, investigate, and resolve problem cases involving COB records, adjusted claims, and overpayments
• Review previously processed claims to ensure payment consistency and maximize overpayment recovery
• Execute procedures to recover funds from providers, subscribers, or beneficiaries when overpayments occur
• Support training, implementations, documentation, and special projects
• Assist with matters involving internal-audit findings, provider-status changes, and system errors
• Perform other job-related duties within the scope of the position