Claims HMO - Complex Claims Specialist 140-1021

Job Summary

The Complex Claims Specialist is responsible for examining claims that require review prior to being adjudicated. Claims are generally of the largest dollar value and require extreme attention to detail and strong knowledge of claims processing.

Key Responsibilities

• Examining and adjudicating claims for multiple lines of business that have pended for review utilizing resources, tools, knowledge and decision-making in determining appropriate actions
• Enter claims information using the processing software, contracts and other agreements to compute payments, allowable amounts, limitations, exclusions and denials
• Identify and communicate trends or problems identified during adjudication process
• Accurately resolves most unique problems or situations without supervisor involvement
• Frequently partners internal departments and with vendors that conduct bill reviews to assist in review and pricing of claims
• Updating reports and tracking of claims information to ensure timeliness in adjudicating claims
• Constantly communicates with internal departments, supervisor, senior leadership and others inside the organization regarding claims, procedures, pricing and various other reasons
• Communicates with providers to obtain records or other materials vital to adjudicating claims
• Contributes to the creation of a pleasant working environment with peers and other departments
• Affords assistance in investigating and solving claims that require additional research
• Consistently learns and adapts to changes related to claims processing, benefits, limits and regulations
• Affords assistance in mentoring or development of new examiners
• Performs other job-related duties as assigned

Qualifications

• Self-motivated and able to work with minimal direction
• Ability to read and understand claims contracts, processing manuals, medical terminology, CPT codes, and perform the most complex processing procedures
• Ability to read and understand health benefit booklets
• Demonstrated learning agility
• Successful completion of Health Care Sanctions background check
• Significant knowledge in the contracted managed care plan terms and rates for multiple lines of business
• Demonstrated understanding of unbundling methods, COB, and other over-billing methodologies
• Demonstrated ability to be detail oriented
• Proficient in Microsoft applications
• Ability to perform basic mathematical calculations
• Demonstrated strong oral and written communication skills

Education/Experience

• High School Diploma or Equivalent required
• Three years related work experience in claims processing, data entry or medical billing
• One year of claims processing experience within CommunityCare or another healthcare environment is required