REMOTE POSITION / CLAIMS PROCESSOR

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.

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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

Leading Utilities Organization