CLAIMS REVIEW SPECIALIST

Job Duties

• Affords assistance with various audits, including 3383 retrospective review audit of crossover claims.
• Maintains and enters information into excel spreadsheets.
• Uploads documentation into Docushare.
• Prepares files for scanning into Docushare.
• Verifies Docushare Scanning.
• Handles incoming and outgoing mail.
• Distributes faxes.
• Performs other duties as assigned to meet changing priorities.

Preferred Qualifications

• Excellent communication skills both written and verbal.
• Ability to work well with others in a professional environment.
• Organization skills to multitask and adapt to changing priorities.
• Previous Medicare, Medicaid, or Commercial Insurance experience is highly sought.
• Familiarity with medical billing and coding is desired.
• Experience With MMIS Interchange Is Preferred.
• Background in research or data analysis is considered a plus.

Position Information

• Job Series: Program Operations – Claims Review
• Classification: Claims Review Specialist
• Class Code: PCR02P
• Pay Grade: SGS03
• Salary Range: $39,171 – $57,973

Job Summary

The Claims Review Specialist plays a critical role in supporting the insurance claims process by reviewing and evaluating claims for accuracy, completeness, and compliance with pre-determined agency policies and regulatory standards. This classification involves verifying claim documentation, investigating discrepancies, and ensuring the timely and efficient resolution of claims.

Primary Responsibilities

• Assess insurance claims to ensure all required information is accurate and complete.
• Verify claim documentation against policy terms and conditions.
• Identify missing or inconsistent information and coordinate with the appropriate personnel to resolve issues.
• Document findings and actions taken for each claim in an organized manner.
• Communicate claim outcomes and provide necessary explanations to policyholders or internal personnel.
• Support fraud detection and prevention efforts by reporting unusual patterns or inconsistencies.
• Stay informed on agency policies, industry practices, and relevant regulations.
• Collaborate with senior team members and managers to improve claims processing workflows.

Knowledge And Skills

• Strong analytical and problem-solving skills, attention to detail, good written and verbal communication.
• Willingness to learn and adapt to new tools, technologies, and processes.
• Experience with using standard office software (e.g., Microsoft Excel, Word).
• A proactive and team-oriented approach to work.
• Familiarity with department related programs.

Minimum Qualifications

• High school diploma or GED.
• Two Years Of Experience In Clerical Or Administrative Functions.

Other Job Related Education And/or Experience May Be Substituted For All Or Part Of These Basic Requirements, Except For Certification Or Licensing Requirements, Upon Approval Of The Qualifications Review Committee.

The State Of Arkansas Is Committed To Providing Equal Employment Opportunities To All Employees And Applicants For Employment Without Regard To Race, Color, Religion, Sex, Pregnancy, Age, Disability, Citizenship, National Origin, Genetic Information, Military Or Veteran Status, Or Any Other Status Or Characteristic Protected By Law.