Claims Specialist
About the role
This position is primarily responsible for processing Medicare and Medicaid subrogation claims received from external vendors in compliance with Medicare Secondary Payer (MSP) laws and internal client configurations. The Claims Specialist also supports internal teams by managing JIRA requests related to claims adjudication issues and serves as a Subject Matter Expert (SME) for claims processing, system testing, audits, and enhancements. This role requires on-site attendance five (5) days per week.
Responsibilities
- Medicare / Medicaid Subrogation
- Serve as the primary point of contact for all Medicare and Medicaid–related inquiries
- Communicate with external vendors regarding subrogation processes and requirements
- Receive, log, and process Medicare and Medicaid subrogation claims
- Review and respond accurately and timely to all demand letters in accordance with regulatory guidelines
- Cross-Functional Collaboration
- Manage the Claims Support email inbox and JIRA queue, ensuring timely and appropriate responses
- Address complex or escalated claims issues and partner with Client Services and Member Services to ensure high levels of customer service
- Provide troubleshooting support for claims adjudication issues across departments
- Client Implementation and System Testing
- Lead claims-related testing components for new client implementations
- Coordinate and perform plan design testing for new clients, new plans, and plan changes
- Collaborate with IT, Implementation, and Client Success teams to resolve system inconsistencies and validate claims adjudication accuracy
- Serve as the claims processing SME during audits, enhancement meetings, and system change testing
- Conduct regression testing following system updates or corrections
- Perform post-implementation monitoring of claims to ensure accuracy and compliance
- Claims Quality Review
- Perform weekly ESI audit reversals
- Monitor and analyze the weekly Unbalanced Claims report
- Identify trends, root causes, and opportunities for process improvement
Requirements
- 3+ years of experience in claims processing or a related insurance field
- Strong understanding of claims processing procedures, benefits administration, coordination of benefits (COB), and reimbursement methodologies
- Proficiency in Microsoft Excel
- Excellent organizational, analytical, and problem-solving skills
- Ability to interpret policy documents, benefit plans, Explanation of Benefits (EOBs), and regulatory guidelines
- Ability to work effectively in a fast-paced environment with shifting priorities
- Ability to work on-site five (5) days per week
Qualifications (Preferred)
- Experience interpreting claims data to support decision-making
- Strong knowledge of HMS rules and regulations
- Experience with Medicare/Medicaid subrogation claim processing
- Experience with plan design configuration and benefits setup
- Familiarity with Medicare/Medicaid regulations, subrogation concepts, and state/federal insurance requirements
Schedule
On-site attendance five (5) days per week.
About the company
Benecard Services, LLC has been administering carve-out, fixed rate insured prescription drug benefit programs since 1990. Benecard is a full-service, in-house prescription benefit administrator that includes mail and specialty drug dispensing. Headquartered in Lawrenceville, New Jersey.
BeneCard PBF provides self-funded prescription benefit program administration with a personalized approach through focused, clinical expertise. Headquartered in Bonita Springs, Florida.
National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health & Welfare Funds, Associations, and Coalitions for over 40 years. Headquartered in Clifton, New Jersey.