Healthcare Claims Specialist - REMOTE

Roles and Responsibilities

• Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms.
• Follows established policies and procedures to pay, pend for additional information, or deny claims.
• Process claims subject to Coordination of Benefits (COB) according to plan benefits, COB rules and contractual reimbursement terms
• Accountable to meet and maintain established department production and quality standards.
• Create claim test cases, execute, and report on the results.
• Identify and communicate defects or claim system issues to those responsible for configuration.
• Work with configuration to remediate and retest defects.
• Identify and communicate inventory issues to department’s management.
• Works with internal departments, vendors, business partners, providers, etc. to help coordinate problem solving in an effective and timely manner.
• Develop and maintain desk top procedures related to claim adjudication.
• Audit auto-adjudicated and/or manually processed claims.
• Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins.

Experience and Skills Desired

• You have a minimum of 3 years' medical claim adjudication/examination experience, working within a health insurance carrier, health insurance TPA, or equivalent.
• You have knowledge of medical and insurance industry terminology including CPT/ICD-10, HCPCS and Revenue Codes.
• You possess strong attention to detail and problem-solving skills with a high level of accuracy.
• You have experience writing desk top procedures.
• You are an excellent communicator, both verbally and in writing.
• You can perform comfortably in a fast-paced, deadline-oriented work environment.
• You are proficient in Microsoft Office applications Word, Excel, Outlook OneNote, etc.
• You have prior experience using a CRM, preferably Salesforce.
• You have prior experience with claim testing and or/auditing.
• You collaborate and support business and operational units such as Customer Service, Medical Management and Appeals and Grievance.
• Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred.
• Bonus: Plexis/Quantum Choice experience.

Benefits Package

• Competitive salary
• Comprehensive health, dental, and vision insurance as well as life and disability
• Retirement savings plan with company match
• Generous time off/vacation
• Professional development opportunities
• Flexible work environment

Telecommuting Requirements

• This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas.
• Must live in the United States within the CST or EST time zones.
• Company business hours are weekdays 9-5 CST.
• Required to have a dedicated work area established that is separate from other living areas and provides information privacy.
• Ability to keep all company sensitive documents secure.
• Must live in a location that receives an existing high-speed internet connection/service.