Claims Specialist

ESSENTIAL DUTIES & RESPONSIBILITIES 

To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to: 

• Serve as a liaison between the plan, claims, providers, and various departments to effectively identify and resolve claims issues.
• Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication. 
• Review, research, solve and process assigned work. This would include navigating multiple computer systems and platforms (e.g. Verify pricing, prior authorizations, applicable benefits) 
• Audit check run and send claims for corrections. 
• Ensure that the proper benefits are applied to each claim by using the appropriate tools, processes, and procedures (e.g. Claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/ certificates tool) 
• Independently complete on a daily basis all documentation and communicate the status of claims as needed adhering to all reporting requirements.
• Communicate through correspondence with members and providers regarding claim payment or required information, using clear, simple language to ensure understanding. 
• Meet and maintain the performance goals established for the position in the areas of quality, production, and attendance. 
• Performs other duties as assigned.

QUALIFICATIONS & EDUCATION 

• High school diploma / GED (or higher) OR 5 years of equivalent working experience. 
• Knowledge of Medical Terminology, coding, and diagnosis coding is helpful. 
• Excellent verbal and written communication skills. 
• Commitment to excellence and high standards.  
• Strong organizational, problem-solving, and analytical skills. 
• Able to manage priorities and workflow.  
• Demonstrates a high level of professionalism in dealing with confidential and sensitive issues. 
• Ability to work effectively, independently and in a team environment.
• Ability to deal effectively with a variety of individuals. 
• Fluency in Spanish and English required.
• Proficiency in computer software (i.e. Microsoft Word, Excel, Power-Point, and Outlook) and the ability to learn new and complex computer system applications (including comfort using short-cut keys/demands). 

WORKING CONDITIONS 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  

• The noise level in the work environment is usually moderate. 
• Interacts with health plan members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances. 
• This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. 
• The work is performed indoors.   
• All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. 
• The work schedule is approximate, and hours/days may change based on company needs.