What are the responsibilities and job description for the Claims Specialist position at Benecard Services Inc.?
The Claims Specialist is primarily responsible for processing Medicare/Medicaid subrogation claims received from various external vendors in accordance with MSP laws and following internal client setup, as well as handling JIRA requests submitted by internal departments to assist with troubleshooting any claims adjudication related issue. Claims specialist is to act as Subject Matter Expert for all claims-related issues, testing and enhancements.
Must report on site 5 days a week
Key Responsibilities
Medicare/Medicaid Subrogation
- Be the point of contact for anything Medicare/Medicaid related
- Communicate with external vendors regarding subrogation process
- Receive, log and process all subrogation claims
- Properly and timely respond to every demand letter
Cross-Functional Collaboration
- Manage Claims Support email box and JIRA queue and ensure timely and proper response
- Address complex or escalated claims and work with client services and member services to ensure high levels of customer service.
Client Implementation and System Testing
- Lead claims-related components of new client implementations testing
- Coordinate and execute plan design testing for new clients, nee plans and changes to the existing plans
- Collaborate with IT, Implementation Teams, and Client Success team to resolve inconsistencies and validate claim adjudication accuracy
- Serve as the subject matter expert (SME) for claims processing during audits, business enhancement meetings, and system change testing
- Conduct regression testing when changes, updates, or corrections are implemented
- Perform post implementation claims monitoring
Claims quality review
- Perform weekly ESI audit reversals
- Monitor Unbalanced Claims weekly report
Qualifications:
Required
- 3 years of experience in claims processing or a related insurance field
- Excellent organizational, analytical, and problem‑solving abilities
- Ability to work in a fast‑paced environment with shifting priorities.
- Strong Microsoft Excel skills
- Strong understanding of claims processing procedures, benefits administration, coordination of benefits (COB), and reimbursement methodologies
- Ability to interpret policy documents, benefit plans, EOBs, and regulatory guidelines
Preferred
- Ability to interpret claims data and make informed decisions.
- Strong experience with HMS rules and regulations and Medicare/Medicaid subrogation claim processing.
- Strong experience in plan design and benefit configuration.
- Familiarity with Medicare/Medicaid claims rules, subrogation concepts, or state/federal insurance regulations is advantageous
Benecard Services, LLC
Benecard Services, LLC has been administering carve-out, fixed rate insured prescription drug benefit programs since 1990. Benecard is a full service, in-house prescription benefit administrator that includes mail and specialty drug dispensing. We are a premiere nationwide Prescription Benefit Administrator headquartered in Lawrenceville, New Jersey.
Website: http://www.benecard.com
BeneCard PBF
BeneCard PBF provides self-funded prescription benefit program administration with a personalized approach through focused, clinical expertise. Our business model operates on a customized claim processing system offering unlimited capability and flexibility to respond to client needs in an evolving marketplace. Advanced clinical programs and advanced technology provide the framework to maximize the use of all data elements available. This allows BeneCard PBF to filter the information, focus on clinical opportunities and facilitate interaction between the physician, the pharmacist and the patient to effectively promote complete health care. Headquartered in Bonita Springs, Florida.
Website: http://benecardpbf.com
National Vision Administrators
For over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health & Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey.
Website: http://www.e-nva.com
We are an Equal Opportunity employer.