Claims Specialist II

About the role

This position supports the claims unit by accurately processing claims edits, determining primacy for Coordination of Benefits (COB), adjusting previously paid claims, and initiating procedures to recover funds on overpaid claims. The role involves analyzing, investigating, and resolving problem cases, executing recovery processes, and completing special projects while complying with all relevant laws and regulations.

This role reports to the Supervisor, Claims Operations and does not involve managing people. Necessary contacts include various internal departments (e.g., Provider Services, Legal, IT, Benefits Operations) and external entities (e.g., providers, members, lawyers, insurance companies, and regulatory bodies).

Responsibilities

• Review, research, and update claims, including recalculating benefits, processing edits, or initiating refund requests according to contractual benefits or provider reimbursement rules to ensure customer satisfaction.
• Maintain a clear understanding of systems, applications, and procedures to identify denial codes, edits, and processing codes for coordinated and non-coordinated claims.
• Request medical records as needed.
• Communicate orally and in writing with internal and external contacts to provide accurate information for establishing sound claim records (e.g., COB, medical record requests).
• Review quality audits for correction or routing within 48 hours to ensure accuracy and customer satisfaction.
• Research, investigate, and determine the correct order of benefits for payment, making necessary corrections to COB records.
• Notify appropriate departments when Medicare has determined primacy incorrectly and ensure a letter is generated to notify Medicare (failure to report may result in fines up to $1,000 per day).
• Analyze, investigate, and resolve problem cases, including COB records, adjusting previously processed claims, and requesting refunds for overpaid claims.
• Review previously processed claims to ensure consistency in payments and maximize recovery of overpayments.
• Execute procedures to recover funds from providers, subscribers, or beneficiaries where overpayments have occurred.
• Assist in training, implementations, and documentation as needed.
• Complete special projects as assigned by management (e.g., internal audit findings, provider status changes, system errors).
• Perform other job-related duties within the scope of responsibilities.

Requirements

• High School Diploma or equivalent (required).
• 2 years of experience in medical claims processing (required).
• Coordination of Benefits (COB) processing experience (preferred).

Skills

• Strong analytical ability, including logical, systemic, and investigative thinking.
• Strong oral and written communication skills, as well as human relations skills.
• Working knowledge of relevant PC software.
• Ability to prioritize multiple streams of work effectively.

Physical Demands

Work is performed in a normal office environment with typical noise levels. Duties are predominately performed while standing or sitting. The role requires the ability to comprehend, document, calculate, visualize, and analyze information.

Residency in or relocation to Louisiana is preferred for this position.