Claims Administrator I

Overview

Medivest Claims Administrators play a vital role in ensuring that fiduciary accounts are administered in full compliance with the standards set forth by the Medicare Secondary Payer (MSP) Statute and applicable regulations. They are tasked with effectively communicating with members, healthcare providers, pharmacies, ancillary supply vendors, attorneys, and insurance companies, demonstrating expertise in MSP compliance. Representatives frequently answer inquiries and proactively reach out to these parties, performing a variety of tasks that require exceptional customer service, communication, and clerical skills.

Essential Duties and Responsibilities

·        Demonstrate, model and expect adherence to the company’s core values and mission.

·        Perform duties in a manner compliant with company policies.

·        Stay informed about changes in industry regulations and company procedures.

·        Communicate clearly and professionally with internal and external stakeholders via phone, video conferencing, and email.

·        Maintain confidentiality and handle sensitive information with discretion and in accordance with HIPAA regulations.

·        Provide exceptional service to clients, members, and colleagues.

·        Address and resolve issues and concerns promptly, escalating complex cases to the appropriate department or manager when necessary.

·        Accurately document all interactions and transactions, ensuring that records are complete, up-to-date, and compliant with company and regulatory requirements.

·        Work collaboratively with team members and other departments to achieve organizational goals.

·        Contribute to a positive team environment.

·        Seek opportunities for professional development and skill enhancement.

·        Participate in training sessions and stay updated on industry trends and best practices.

·        Prioritize tasks effectively to meet deadlines and organizational objectives.

·        Identify issues and propose solutions proactively.

·        Take initiative to improve processes and enhance service delivery.

·        Adapt to changing priorities, projects, and work environments.

·        Embrace new challenges and changes with a positive attitude.

Department Specific Responsibilities

·        Enter new claims and reimbursement requests into Medivest’s proprietary system.

·        Adjudicate claims in accordance with applicable agreements, medical fee schedules, and Medicare Secondary Payer standards.

·        Review quotes and authorizations from medical/supply vendors.

·        Coordinate benefits between payers, providers, and miscellaneous third parties.

·        Review and respond to claim appeals submitted by providers or members.

·        Assist in the processing and mailing of the weekly check run.

·        Ability to coordinate benefits with medical providers and insurance companies.

·        Explain relevant account coverage and funds guidelines to providers or members.

Education and Experience Qualifications

·        High School Diploma/GED

·        Minimum 2 years’ experience working in a medical office setting, preferably with payment processing and/or PHI handling.

·        Basic knowledge of workers’ compensation and general liability insurance claims industry – Preferred

·        Entry level knowledge of medical coding and/or medical claims processing

Skills & Abilities Requirements

·        Independent decision making, negotiation, and problem-solving skills

·        Ability to work in small teams on dynamic projects

·        Strong analytical skills to assess service issues and develop effective solutions

·        Excellent verbal and written communication skills, with the ability to explain complex regulatory concepts to both internal teams and clients

·        Highly motivated and task-oriented, capable of managing a heavy workload, responding quickly to inquiries, and maintaining attention to detail

·        Strong time management skills, able to maintain productivity and focus without distraction

·        Quick learner with a high aptitude for and commitment to mastering industry-specific knowledge, particularly within the MSP sector

·        Proficiency in the use of common office technology, including software such as Microsoft Office Suite, Microsoft 365, and Adobe

·        Fluent in both Spanish and English, with outstanding oral and written communication skills in both language (preferred, not required).

Benefits          

Medical/Dental/Vision, 401K, Company paid holidays, possibility of accruing up to 3 weeks paid time off per year

Schedule

Full time,  Monday – Friday form 8 am – 5pm EST

Base Rate

Starting at $20-$21 (based on industry specific experience)