Claims Specialist III

Our client is a Tailored Plan and Managed Care Organization serving 46 counties across North Carolina. It manages services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/developmental disabilities. The organization focuses on helping individuals and families build strong foundations for healthy, fulfilling lives.

About the Role

The Claims Specialist III is responsible for managing and coordinating claim issues submitted by providers, members, or other entities through various communication channels. The role includes researching claim issues, providing support and information to the provider community, and ensuring timely and accurate responses, including escalations from the State Department. This position contributes to maintaining effective claims processing and communication, supporting the organization's service delivery.

Responsibilities

• Manage and coordinate calls and tickets related to claim issues.
• Update and respond to claims ticket queues and call logs promptly.
• Conduct claims research using multiple sources and collaborate with claims staff.
• Assist with drafting communications for providers.
• Analyze trends in provider issues and recommend updates to claims systems and staff training.

Requirements

• High school diploma or GED with six years of relevant experience, or
• Associate's degree with four years of relevant experience, or
• Bachelor's degree with two years of relevant experience, or
• Equivalent combination of education and experience.
• Valid driver’s license.
• Residency within North Carolina.
• Ability to travel within the service area as required.
• Preferred: degree in Business Administration, Healthcare Administration, Human Services, Public Administration, Liberal Arts, or Humanities.
• Preferred: experience in the public mental health field.

Pay

Salary range: $56,270 to $69,898.

Benefits

• Typical working hours: 8:30 am to 5:00 pm with flexible schedules.
• Work-from-home options for most positions.
• Health insurance with no premium for employee coverage.
• Flexible Spending Accounts.
• 24 days of Paid Time Off plus 12 paid holidays in the first year.
• North Carolina Local Government Retirement Pension (defined-benefit plan).
• 401(k) with 5% employer match and immediate vesting.
• Public Service Loan Forgiveness qualifying employer.
• Quarterly stipend for remote work supplies.