Claims Specialist III

Role Overview

• The Claims Specialist III is responsible for capturing, resolving/facilitating resolution, and reporting on claim adjustment requests
• Resolve complex COB issues through member information updates and adjustment of claims
• Maintain accountability for daily tasks and goals to ensure completion of requests within requested SLA and department standards
• Identify potential process improvements
• Work with peers to ensure implementation of identified process improvements through the Plan, Do, Study, Act (PDSA) cycle with proper documentation updates and sharing of improvement with team and department
• Process/adjust a wide variety of claims accurately and timely following established guidelines for accuracy, quality and productivity
• Act as a technical resource for training, providing job shadowing, departmental communication, and coaching
• Ensure all assigned provider issues are resolved and communicated to the provider within appropriate timeframes and claims resolutions are coordinated with all appropriate departments in order to resolve
• Assist providers with inquiries including but not limited to; verifying proper medical coding, explanation of benefits, negative balance requests, claims, and appeal procedures
• Identify, track and trend claims payment errors in order to determine root causes and actions needed to correct problems. Work directly with Configuration, Network Operations, and Service Center through resolution of payment errors.
• Ensure reporting on provider inquires and complaints is compliant with current and future regulatory and accreditation bodies such as; ODJFS, MDCH, CMS, OFIR, NCQA and URAC
• Adhere to all HIPAA, State, and Federal requirements and regulations at all times in existing and future lines of business

Requirements

• High School Diploma or equivalent is required
• Minimum of one (1) year of experience in claims environment or related healthcare operations experience required
• Previous experience in an HMO or related industry preferred
• Previous Medicare/Medicaid dual eligible claims experience is preferred
• Managed Care Organization or related healthcare industry experience preferred
• Proficient in Microsoft Office Suite, to include Word, Excel and PowerPoint
• Medical terminology; CPT and ICD coding knowledge strongly preferred
• Knowledge of medical billing practices
• Intermediate level data entry skills

Benefits

• comprehensive total rewards package