Claims Specialist II

Job Description

Job Description

Claims Specialist II - Medical Claims & Coordination of BenefitsPut Your Claims Experience to Work

Are you an experienced medical claims professional who enjoys solving complex problems, researching payment issues, and making sure claims are processed correctly?

We're looking for a Claims Specialist II to join a healthcare claims operations team. In this role, you'll investigate and resolve medical claims issues, process adjustments, research Coordination of Benefits (COB), correct payment discrepancies, and help recover overpayments.

If you have at least 2 years of hands-on medical claims processing experience and enjoy digging into the details to figure out what happened and how to fix it, we'd love to hear from you.

Medical claims processing experience is REQUIRED. COB experience is highly preferred.

What You'll Do

You'll take ownership of medical claims from research through resolution, helping ensure claims are processed accurately, efficiently, and according to established benefits and reimbursement guidelines.

• Review, research, and process medical claims.
• Investigate claims edits, denial codes, processing codes, and payment discrepancies.
• Adjust and reprocess previously paid claims when necessary.
• Recalculate benefits based on plan and provider reimbursement requirements.
• Research Coordination of Benefits (COB) and determine primary versus secondary insurance coverage.
• Apply COB rules involving subscriber status, effective dates, plan types, Medicare coordination, and other coverage factors.
• Research and correct inaccurate COB and coverage records.
• Communicate with members, providers, and other insurance carriers to verify coverage and resolve claims issues.
• Identify overpayments and initiate refund or recovery processes.
• Review previously processed claims to identify additional recovery opportunities.
• Request and review medical records when needed to support claims research.
• Review quality audit findings and complete required corrections within established timelines.
• Maintain accurate and complete claims documentation.
• Partner with Provider Services, Enrollment & Billing, Legal, Internal Audit, IT, and other departments to resolve complex issues.
• Assist with special projects, audits, system issues, training, implementations, and process improvements as needed.

What We're Looking ForRequired Qualifications

• High School Diploma or equivalent.
• Minimum 2 years of hands-on medical claims processing experience .
• Strong understanding of healthcare claims processing and adjudication.
• Experience researching and res