Claims Specialist II

About the role

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/developmental disabilities (IDD). Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.

Responsibilities

• Analyze and audit claims adjudication results to determine if claims were accurately submitted and processed according to NC Medicaid guidelines.
• Analyze and audit claim attachments/medical documentation necessary to appropriately adjudicate a claim.
• Analyze, audit and take appropriate actions for claims delayed for adjudication due to rejection errors.
• Identify adjudication errors, provider billing errors, and the need for technical assistance.
• Ensure the claims system and manual processes are incorporating required actions by reviewing and applying information from departmental trainings, published coverage policies and other NCDHHS documents.
• Provide training, education and technical assistance to provider agencies based on analysis or audit findings related to basic claim submission guidelines, denial management, system use and updates.
• Recognize and report suspected system issues or concerns to immediate supervisor for follow-up based on data analysis.
• Assist providers by phone or email with claims processing questions.
• Communicate with internal and external stakeholders to facilitate efficient claims resolution.

Requirements

• High School Diploma/GED and two (2) years of experience in claims processing, billing, or medical coding; OR Equivalent combination of education/experience.
• Must have a valid driver’s license.
• Must reside within North Carolina.
• Must be able to travel within catchment as required.

Preferred Qualifications

• Associate’s degree in Healthcare Administration, Business, or a Human Services field (such as Psychology, Social Work, etc.).
• Hospital claims experience and knowledge.
• Experience in the areas of physical health claims processing or medical coding.
• Experience working with Managed Care billing software.
• Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS) or similar certification preferred.

Benefits

• Health Insurance with no premium for employee coverage.
• Flexible Spending Accounts.
• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year.
• NC Local Government Retirement Pension (defined-benefit plan).
• 401k with 5% employer match and immediate vesting.
• Public Service Loan Forgiveness (PSLF) qualifying employer.
• Quarterly stipend for remote work supplies.

Pay

$42,765 – $61,546

Schedule

Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval. Work-from-home options available for most positions.