Claims Assistant

Position Summary

The Claims Assistant supports the Claims and Complaints & Grievances departments by performing administrative, data entry, and claims support functions. This position is responsible for the accurate and timely entry, tracking, and processing of claims-related information while ensuring compliance with departmental procedures, quality standards, and regulatory requirements. The Claims Assistant works closely with Claims Examiners, Customer Service, Utilization Management, and Provider Services to support efficient claims operations.

Essential Position Functions/Responsibilities

• Accurately enter claim submissions, claim reconsiderations, Complaints & Grievances, and special project claims into the EZ-CAP claims system.
• Review and verify claim information to ensure complete and accurate claim registration.
• Perform basic claim adjustments and updates according to established procedures.
• Affix with pharmacy claim pricing using approved databases and resources.
• Request, track, and coordinate medical records and supporting documentation for claims review.
• Contact provider offices to obtain missing claim information, referrals, authorizations, and provider details.
• Review notifications from Utilization Management, create claims as needed, and notify Claims Examiners of claims requiring processing.
• Review, update, and close Customer Service incidents related to claims inquiries and processing.
• Affix with the processing and tracking of Complaints & Grievances to ensure timely resolution.
• Maintain electronic records and documentation in accordance with departmental procedures.
• Meet established productivity, quality, and turnaround time standards.
• Maintain a minimum quality standard of 98% procedural accuracy.
• Comply with HIPAA, company policies, and applicable regulatory requirements.
• Participate in overtime, evening, or weekend schedules as needed to meet operational and compliance requirements.
• Perform other duties as assigned.

Qualification Requirements

• Basic knowledge of medical terminology, healthcare claims processing, or insurance operations preferred.
• Familiarity with ICD-10 diagnosis coding and CPT/HCPCS procedure coding preferred.
• Strong data entry skills with excellent attention to detail.
• Proficiency in Microsoft Office applications, including Word, Excel, and Outlook.
• Strong verbal and written communication skills.
• Ability to work in a fast-paced, production-driven environment.
• Strong organizational and time-management skills.
• Ability to prioritize tasks and meet deadlines.
• Ability to work independently and as part of a team.

Training/Education

• A High School Diploma or GED required.
• Courses or training in healthcare administration, medical billing and coding, or a related field is a plus.

Experience

• Minimum one (1) year of data entry or administrative experience, preferably in a healthcare or insurance environment.
• Previous claims, medical billing, customer service, or healthcare administrative experience preferred.
• Experience with EZ-CAP or other healthcare claims systems is a plus.