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Medical Claims Specialist

2 months ago

Lake Forest, California, United States PrideStaff Full time
Job Summary

PrideStaff is seeking a highly organized and detail-oriented Medical Claims Specialist to join our team. As a Medical Claims Specialist, you will be responsible for qualifying claims/bills for payment, checking for coverage, and applying co-pays, deductibles, and coinsurance.

Key Responsibilities
  • Claims Processing: Import claims received into specified cases, review and verify personal information, and check for coverage and apply co-pays, deductibles, and coinsurance.
  • Case Management: Create cases and assist with incoming calls, working closely with other departments to ensure seamless communication.
  • Claims Review: Review claims which may require direct network contact, and responsible for contributing to cost containment efforts by validating bills for services rendered, authenticity, and reasonable and customary charges.
  • Dispute Resolution: Handle disputes and process corrected and reworked claims.
  • Manager Inboxes: Manage inboxes for multiple insurance providers, including Gotham Insurance, Aetna Insurance, and United Insurance.
  • Adherence to Guidelines: Adhere to company policies and local, state, and federal guidelines when facilitating claims processing.
Requirements
  • Education: High School diploma, GED, or equivalent to 1+ years of customer service experience OR experience in a medical office, healthcare Call Center, or Office setting analyzing and solving customer problems.
  • Experience: MUST HAVE prior work experience opening cases and qualifying claims/bills for payment, checking for coverage, and applying co-pays, deductibles, and coinsurance.
  • Technical Skills: MUST HAVE fluency in basic computer systems like Microsoft Office, and/or risk assessment software.
  • Communication Skills: Strong critical thinking, problem-solving, decision-making, and communication skills.