Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms.
Follows established policies and procedures to pay, pend for additional information, or deny claims.
Process claims subject to Coordination of Benefits (COB) according to plan benefits, COB rules and contractual reimbursement terms.
Accountable to meet and maintain established department production and quality standards.
Create claim test cases, execute, and report on the results.
Identify and communicate defects or claim system issues to those responsible for configuration.
Work with configuration to remediate and retest defects.
Identify and communicate inventory issues to department’s management.
Works with internal departments, vendors, business partners, providers, etc. to help coordinate problem solving in an effective and timely manner.
Develop and maintain desk top procedures related to claim adjudication.
Audit auto-adjudicated and/or manually processed claims.
Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins.

You have a minimum of 3 years' medical claim adjudication/examination experience, working within a health insurance carrier, health insurance TPA, or equivalent.
You have knowledge of medical and insurance industry terminology including CPT/ICD-10, HCPCS and Revenue Codes.
You possess strong attention to detail and problem-solving skills with a high level of accuracy.
You have experience writing desk top procedures.
You are an excellent communicator, both verbally and in writing.
You can perform comfortably in a fast-paced, deadline-oriented work environment.
You are proficient in Microsoft Office applications Word, Excel, Outlook OneNote, etc.
You have prior experience using a CRM, preferably Salesforce.
You have prior experience with claim testing and or/auditing.
You collaborate and support business and operational units such as Customer Service, Medical Management and Appeals and Grievance.
Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred.
Bonus: Plexis/Quantum Choice experience.

Competitive salary
Comprehensive health, dental, and vision insurance as well as life and disability
Retirement savings plan with company match
Generous time off/vacation
Professional development opportunities
Flexible work environment

Healthcare Claims Specialist

Key skills