Description

Job Title: Medical Claims Specialist - Remote

Stafford Communications is uniquely different. Stafford Communications, a division of Premier BPO specializes in customer service, compliance and marketing in support of many prestigious brands in in pharmaceutical, healthcare, food, consumer packaged goods and beauty care companies – ensuring their customer service initiatives are aligned to their marketing programs.

Job Summary:

The Medical Claims Specialist - Remote is responsible for the review, investigation, decision making, and processing of production claim types, and all related claim functions and activities. Production claims are those claims under $5,000.

Essential Duties and Responsibilities:

• Review and adjudicate all types of claims designated as “production claims”, meeting production and quality goals.
• Review, investigate, and apply all necessary criteria to determine validity of claim.
• Understand the Anthem JAA workflow and apply JAA processing procedures, rules, and guidelines to adjudicate JAA claims.
• Apply benefit plan rules and processing guidelines to pay, pend, or deny claims.
• Manage and follow up timely on all pending claims and correspondence, including review of patient claim history.
• Prepare and generate accurate claim EOB messages and correspondence.
• Review and determine eligibility and coverage for specific group/plan.
• Research claim problems and take necessary actions to resolve.
• Utilize training and on-line documentation to keep up to date on processing guidelines, insurance principles, DOL rules and regulations, and benefit plan rules.
• Update claims system with applicable claim/and patient notes.
• Perform COB, No-fault, Pre-existing, and other claim investigations.
• Contact employers, providers, participants, as necessary.
• Identify correct providers, PPOs, and ensure that appropriate pricing is obtained.
• Perform non-complex claim adjustments, including handling of customer service referrals and take appropriate steps to initiate adjustments on JAA claims.
• Troubleshoot utilization review and medical necessity related issues utilizing AMM or other UR vendor’s website information, and route claims for review accordingly.
• Utilize Claim Workflow system for work assignments, routing, and follow up.
• Handle other claim-related duties, projects, and assignments as assigned, including the handling of claim exceptions and provider not found claims.

Education and/or Experience:

• One to two years of college or equivalent experience.
• Minimum one years’ claims experience.
• Familiarity with Eldorado Software is a plus.
• Medical billing and/or AMA coding experience preferred.
• Data Entry experience or equivalent type work using keyboard/PC.

Knowledge and skills:

• Knowledge of insurance and medical terminology.

• High level of keyboard/PC skills.

• Excellent oral and written communication skills.

• Good judgment and decision-making abilities.

• Good analytical and math skills.

• Good interpersonal skills and willingness to assist others.

• Basic knowledge of Word and Excel.

Pay, benefits and more:

We are eager to attract the best, so we offer competitive compensation and a generous benefits package, including full health insurance (medical, dental and vision), 401(k), life insurance, disability and more.