Claims Specialist I
1 week ago
Job Summary
The Claims Specialist resolves medical claims that are not automatically adjudicated by the claims processing system in a timely and accurate manner according to divisional standards of quality and productivity. Resolution may include additional investigation or communication in order to obtain necessary information to complete the claim. Outside issues such as peak filing season, systems down time, inclement weather, holidays, and absenteeism may directly affect the volume of work for each Specialist
Requirements
EDUCATION
High School diploma or equivalent.
Experience
Minimum two (2) years' college coursework (48 semester hours) or other equivalent certification with an emphasis in anatomy, medical terminology, math, biology, or a related field. OR minimum one (1) year of related office experience such as claims processing, health insurance, or medical office.
Must pass company proficiency test: Claims Assessment
Essential Skills & Abilities
Oral & Written Communications
Strong Interpersonal skills
Sound Judgement
Decision Making
Detail-Oriented
Teamwork
Dependability
Skills
Clinical Judgment, Decision Making, Detail-Oriented, Interpersonal Relationships, Oral Communications, Written Communication
Responsibilities
Claims Processing: Claims processing involves the actions required to pay or deny pended claims (those which did not auto-adjudicate), including: entering data into the system; reviewing and interpreting contract benefits; conducting edit and audit resolution; determining benefit eligibility; Identifying and researching processing issues through systems and manuals; routing claims to other areas; consulting internal staff and medical providers; generating correspondence; and completing forms to obtain necessary information, Knowledge/Continuous Learning: In order to perform the actions required of the Claim Specialist job, the incumbent must undergo initial training, on-the-job training, and continuing education. Demonstrating knowledge of and possessing the ability to access all relevant computer systems and screens in order to process claims accurately; staying current with continually changing processing procedures, benefits, and system modifications; being knowledgeable of and able to meet corporate and national (MTM) standards while maintaining acceptable performance levels based on established departmental standards for productivity and quality; and showing familiarity with corporate and professional manuals and guidebooks, including the company processing manual and ICD, CPT, and HCPS codebooks, Other duties: As assigned
Certifications:
MBE Certification
The Western Regional Minority Supplier Development Council Certificate # WR03208
MBE Certified by CPUC, California Public Utilities Commission (VON: 15030026)
DBE certified by VTA California Unified Certification Program (File No: 040243)
Small Business Certified by GSA, The state of California.
Our Team consists of trained and committed Management Professionals divided into various groups. Our entire team has extensive experience and success in this service sector which allows ABCS to provide our clients with the best-customized solution and top tier quality service
Our Goal is to offer each customer a consultative partnership and customized industry-specific solutions to meet their business challenges, get maximum ROI, meet budgetary guidelines and achieve operational excellence, which in turn builds long-term business partnerships. Accomplished through a consultative and collaborative process to ensure success for our clients and ABCS. As a result, we are highly motivated in identifying top tier technology professionals that meet the expectations of our discerning customers.
Specialties
Direct Hire, Contract Hire, Resource Management, Human Capital, Executive Leadership Recruitment, IT Executive Recruitment, Java, J2EE, Network Security, QA/QE Engineers, Hadoop, MapReduce, Cassandra, Hive, HBase, PIG, and Web Development.Company DescriptionABCS is one of the finest IT Executive and Contingent Workforce Staffing company in the United States that provides clients with comprehensive IT Staffing services and efficient solutions from our 2 offices located in San Jose, CA and Phoenix, AZ. We understand the value of time and its importance to each customer...our focus is to ensure completion of each project/SOW/Assignment, minimizing "down time" for our customers, meeting project timeline and exceeding customer expectations.\r
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Certifications: \r
\r
MBE Certification \r
The Western Regional Minority Supplier Development Council Certificate # WR03208\r
MBE Certified by CPUC, California Public Utilities Commission (VON: 15030026) \r
DBE certified by VTA California Unified Certification Program (File No: 040243)\r
Small Business Certified by GSA, The state of California. \r
Our Team consists of trained and committed Management Professionals divided into various groups. Our entire team has extensive experience and success in this service sector which allows ABCS to provide our clients with the best-customized solution and top tier quality service\r
\r
Our Goal is to offer each customer a consultative partnership and customized industry-specific solutions to meet their business challenges, get maximum ROI, meet budgetary guidelines and achieve operational excellence, which in turn builds long-term business partnerships. Accomplished through a consultative and collaborative process to ensure success for our clients and ABCS. As a result, we are highly motivated in identifying top tier technology professionals that meet the expectations of our discerning customers.\r
\r
Specialties\r
Direct Hire, Contract Hire, Resource Management, Human Capital, Executive Leadership Recruitment, IT Executive Recruitment, Java, J2EE, Network Security, QA/QE Engineers, Hadoop, MapReduce, Cassandra, Hive, HBase, PIG, and Web Development.
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