Claims Specialist

About the role

We’re looking for a detail-oriented Claims Specialist to join our team in Southern Utah. This role is ideal for someone who understands healthcare claims, enjoys solving problems, and takes pride in helping members and healthcare providers navigate the claims and reimbursement process. You’ll review and process medical, dental, and vision claims, ensuring accuracy and timely reimbursements while working closely with members, healthcare providers, and internal teams to research issues and resolve discrepancies.

Responsibilities

• Review and process medical, vision, and dental claims.
• Maintain a clear understanding of all current plans and their benefit features.
• Maintain required productivity and quality standards.
• Identify process improvement opportunities.
• Send and track medical record requests.
• Communicate with healthcare providers and members regarding claim and reimbursement status and requirements.
• Maintain accurate records of claims and reimbursements.
• Identify and correct discrepancies in claims.
• Send and track provider refund requests.
• Ensure timely reimbursement for services.
• Monitor claim status and follow up on outstanding claims.
• Serve as a backup for clerk tasks during employee absences.
• Answer questions and provide resources to different team members.
• Other duties as assigned.

Requirements

• Experience in claims and/or billing.
• Understanding of medical terminology.
• Basic knowledge of healthcare concepts including network status, reference base pricing / UCR, deductible, coinsurance, co-pay, out-of-pocket maximum, inside limits and exclusions, and plan variations.
• ICD-10, CPT, HCPCS, CDT knowledge.
• Basic understanding of coordination of benefits.
• Excellent communication skills.
• Must be a team player yet able to work independently.
• Attention to detail.
• Ability to multi-task and prioritize.
• Knowledge of appeal and subrogation is preferred.

Benefits

• 12 paid holidays plus 3 weeks of paid time off.
• Comprehensive insurance coverage including health, dental, vision, and accident plans.
• Free membership for you and your dependents to Primestin Care Clinic.
• 401k plan with a 4% company match.
• Free snacks and regular lunches available onsite.

Pay

$23–$25 USD per hour.