Claims Specialist

To support the claims unit, the full-time remote Claims Specialist III will manage the accurate processing of claims edits, determine primacy for Coordination of Benefits (COB), adjust previously paid claims, and resolve complex cases while ensuring compliance with regulations and high levels of member/provider satisfaction. Key responsibilities Accurately process complex claims and adjustments, including escalated cases and special projects, to meet contractual obligations Analyze and resolve problem cases, ensuring proper order of benefits and executing recovery processes for overpaid claims Assist in training staff, developing system changes, and communicating with internal and external stakeholders regarding claims processing Required qualifications High School Diploma or equivalent required 4 years of experience in Coordination of Benefits (COB) or adjustments/refunds processing required Self-funded processing experience preferred Strong background in claims coding, processing, and adjustments Full understanding of claims procedures and primacy rules necessary