Medical Claims Specialist

3 weeks ago


Columbia, South Carolina, United States Spectraforce Technologies Full time
Job Title: Medical Claims Specialist

At Spectraforce Technologies, we are seeking a skilled Medical Claims Specialist to join our team. As a Medical Claims Specialist, you will be responsible for performing medical reviews using established criteria sets and/or performing utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. You will also be responsible for documenting decisions using indicated protocol sets or clinical guidelines.

Responsibilities:
  • 80% May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
  • Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
  • Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made.
  • 10% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
  • 10% Participates in quality control activities in support of the corporate and team-based objectives. Participates in all required training.
Required Education: Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. Required Experience: 2 years clinical experience. Required Licenses and Certificates: Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire. Preferred Education: Associate Degree- Nursing OR Graduate of an Accredited School of Nursing. Preferred Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). Language: English.

  • Columbia, South Carolina, United States Washington Medical Supplies Full time

    Job SummaryWe are seeking a highly skilled Medical Billing Clerk to join our team at Washington Medical Supplies. As a Medical Billing Clerk, you will be responsible for coordinating all Medicare/Medicaid/Insurance billing and prior authorizations.Key Responsibilities:• Coordinate all insurance billing and prior authorizations under general supervision.•...


  • Columbia, South Carolina, United States Midlands Neurology and Pain Associates, P.A. Full time

    Medical Billing Specialist Position Overview At Midlands Neurology and Pain Associates, P.A., we are seeking a highly skilled Medical Billing Specialist to join our team. As a Medical Billing Specialist, you will be responsible for managing all aspects of billing, including accounts receivables, claims submission, and payment posting. You will work closely...


  • West Columbia, South Carolina, United States BlueCross BlueShield of South Carolina Full time

    Job SummaryWe are seeking a skilled Claims Customer Service Advocate I to join our team at BlueCross BlueShield of South Carolina. In this role, you will be responsible for responding to routine inquiries, identifying incorrectly processed claims, and completing adjustments and related reprocessing actions.Key ResponsibilitiesRespond to customer inquiries...


  • Columbia, South Carolina, United States BCA Financial Services, Inc. Full time

    Remote Insurance Claims Collector OpportunityBCA Financial Services, Inc. is seeking a detail-oriented Insurance Claim Collector to work from home. The ideal candidate will have a minimum of 2 years medical insurance billing and claims follow-up experience.Key Responsibilities:Work with insurance companies to determine the cause of denial or non-payment of a...


  • West Columbia, South Carolina, United States BlueCross BlueShield of South Carolina Full time

    Job SummaryWe are seeking a skilled Customer Service Advocate II - Claims Specialist to join our team at BlueCross BlueShield of South Carolina. As a key member of our customer service team, you will be responsible for responding to customer inquiries, researching and resolving complex claims issues, and providing exceptional service to our members.Key...


  • West Columbia, South Carolina, United States BlueCross BlueShield of South Carolina Full time

    Job SummaryWe are seeking a skilled Customer Service Advocate II - Claims Specialist to join our team at BlueCross BlueShield of South Carolina. As a key member of our customer service team, you will be responsible for responding to customer inquiries, researching and resolving claims, and providing exceptional service to our members.Key...

  • PFS Biller

    4 weeks ago


    Columbia, South Carolina, United States Prisma Health Full time

    Job SummaryWe are seeking a skilled PFS Biller to join our team at Prisma Health. As a PFS Biller, you will be responsible for accurately and timely submitting claims to various payer sources, following timely filing guidelines. Your attention to detail and ability to work independently will be essential in ensuring the success of this role.Key...

  • Claims Adjuster

    4 weeks ago


    Columbia, South Carolina, United States Club Car Wash Full time

    Club Car Wash Career OpportunityWe are seeking a skilled Claims Agent to join our team at Club Car Wash, one of the fastest growing tunnel car wash companies in the United States. As a Claims Agent, you will play a critical role in reviewing and investigating property claims filed with our company, helping and assisting our customers with their needs,...


  • Columbia, South Carolina, United States Physician Services Full time

    Physician Services is seeking a skilled Medical Billing Specialist to join their team. As a key member of the revenue cycle team, you will be responsible for managing the billing and account resolution aspects of revenue cycle management.Responsibilities include:Review and submit claims daily within the client practice management system.Apply incoming ERA...


  • Columbia, South Carolina, United States Addison Group Full time

    Job Title:Medical Underwriting SpecialistJob Summary:The Medical Underwriting Specialist will be responsible for evaluating health applications and medical records to ensure adherence to underwriting guidelines. This role requires adaptability, attention to detail, and effective communication.Key Responsibilities:Evaluate Applications:Review health...


  • Columbia, South Carolina, United States Forhyre Full time

    Job Title: Claims Business AnalystWe are seeking a skilled Claims Business Analyst to join our team at Forhyre. As a Claims Business Analyst, you will play a vital role in supporting the successful completion of analytical, building, testing, and deployment tasks of our software product's features.This role will work collaboratively with the Director of...


  • Columbia, South Carolina, United States Forhyre Full time

    Job Title: Claims Business AnalystWe are seeking a skilled Claims Business Analyst to join our team at Forhyre. As a key member of our organization, you will play a vital role in supporting the successful completion of analytical, building, testing, and deployment tasks of our software product's features.This role will work collaboratively with the Director...


  • West Columbia, South Carolina, United States Doctors CareUCI Medical Affiliates, Inc. Full time

    Accounts Receivable SpecialistDoctors Care/UCI Medical Affiliates, Inc. is seeking a highly skilled Accounts Receivable Specialist to join our team. As a key member of our Patient Accounting department, you will be responsible for resolving outstanding, unpaid, unprocessed, and denied claims submitted to third-party payers on behalf of our providers.Key...


  • Columbia, South Carolina, United States Addison Group Full time

    Job Title:Medical Underwriting SpecialistLocation:Columbia, TN (Onsite position)Industry:HealthcarePay:$17.50/hrContract position through JanuaryAbout Our Client:Addison Group is a prominent organization specializing in insurance, committed to delivering high-quality service and maintaining rigorous standards. They are currently seeking a dedicated Medical...

  • Appeals Specialist

    4 weeks ago


    Columbia, South Carolina, United States BlueCross BlueShield of South Carolina Full time

    Appeals Specialist Opportunity at BlueCross BlueShield of South CarolinaWe are seeking a skilled Appeals Specialist to join our team at BlueCross BlueShield of South Carolina. In this role, you will be responsible for performing non-medical reviews and making requested corrections on submitted claims.Key Responsibilities:Conduct thorough reviews of appeals...


  • Columbia, South Carolina, United States Columbia Orthopaedic Group Full time

    Position: Physician Support StaffHours: Full-time, Monday to FridayJob Summary:We are seeking a dedicated and organized individual to provide crucial support to physicians and other healthcare professionals in delivering high-quality patient care. The successful candidate will assist with various tasks including administrative duties, patient communication,...


  • Columbia, South Carolina, United States Maury Regional Hospital Full time

    Job Title: Billing SpecialistMaury Regional Health is seeking a skilled Billing Specialist to join our team. As a key member of our revenue cycle team, you will be responsible for the accurate and timely processing of home health claims.About the Role:This is a full-time dayshift position at Maury Regional Medical Center in Columbia, TN. The ideal candidate...


  • Columbia, South Carolina, United States WNS Global Services Full time

    Job SummaryWe are seeking a highly skilled and bilingual Insurance Claims Representative to join our team at WNS Global Services. As a key member of our claims team, you will be responsible for handling inbound calls, assisting agencies and insurers with policy and claims-related queries, and providing exceptional customer service.Key ResponsibilitiesReceive...


  • West Columbia, South Carolina, United States Doctors CareUCI Medical Affiliates, Inc. Full time

    Position Title: Accounts Receivable SpecialistSpecialty: Credit Balance (Experienced Professional)Location: Columbia, South CarolinaFull Time/Part Time: Full TimeCompany Overview:UCI Medical Affiliates, Inc. (UCI) provides non-medical management and administrative services to over 50 Doctors Care urgent care centers and 24 Progressive Physical Therapy...


  • Columbia, South Carolina, United States Williamson Health Full time

    Job SummaryWilliamson Health is seeking a highly skilled Medical Coding Specialist II to join our team. As a key member of our healthcare team, you will be responsible for ensuring accurate and timely charge entry for patients in our facility.Key ResponsibilitiesEnsure accurate input of E&M and Surgery Charges in the EMR and billing systems.Timely entry and...