Remote - Claims Specialist Iii - R6269

Job Summary
The Claims Specialist III is responsible for capturing, resolving/facilitating resolution, and reporting on claim adjustment requests.
Essential Functions

• Maintain accountability for daily tasks and goals to ensure completion of requests within requested SLA and department standards
• Act as a technical resource for training, providing job shadowing, departmental communication, and coaching
• Ensure reporting on provider inquires and complaints is compliant with current and future regulatory and accreditation bodies such as; ODJFS, MDCH, CMS, OFIR, NCQA and URAC
• Perform any other job related instructions, as requested
• Work with peers to ensure implementation of identified process improvements through the Plan, Do, Study, Act (PDSA) cycle with proper documentation updates and sharing of improvement with team and department
• Identify, track and trend claims payment errors in order to determine root causes and actions needed to correct problems. Work directly with Configuration, Network Operations, and Service Center through resolution of payment errors.
• Resolve complex COB issues through member information updates and adjustment of claims
• Adhere to all HIPAA, State, and Federal requirements and regulations at all times in existing and future lines of business
• Process/adjust a wide variety of claims accurately and timely following established guidelines for accuracy, quality and productivity
• Assist providers with inquiries including but not limited to; verifying proper medical coding, explanation of benefits, negative balance requests, claims, and appeal procedures
• Identify potential process improvements
• Ensure all assigned provider issues are resolved and communicated to the provider within appropriate timeframes and claims resolutions are coordinated with all appropriate departments in order to resolve

Education And Experience

• Previous Medicare/Medicaid dual eligible claims experience is preferred
• High School Diploma or equivalent is required
• Minimum of one (1) year of experience in claims environment or related healthcare operations experience required
• Managed Care Organization or related healthcare industry experience preferred
• Previous experience in an HMO or related industry preferred

Competencies, Knowledge And Skills

• Ability to coach and provide feedback effectively
• Knowledge of medical billing practices
• Effective listening and critical thinking skills
• Proficient in Microsoft Office Suite, to include Word, Excel and PowerPoint
• Ability to develop, prioritize and accomplish goals
• Medical terminology; CPT and ICD coding knowledge strongly preferred
• Intermediate level data entry skills
• Strong interpersonal skills and a high level of professionalism
• Ability to work independently and within a team environment
• Effective problem solving skills with attention to detail
• Excellent written and verbal communication skills

Licensure And Certification

• None

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range
$38,100.00 - $61,000.00
Compensation Type
Hourly