Claims Support Specialist
2 weeks ago
Position Summary
The Claims Support Specialist plays a vital role in managing care coordination and conducting utilization assessments by engaging in data gathering and entry. This position involves effective communication with Nurse Case Reviewers/Managers, healthcare providers, employers, and claimants regarding their workers' compensation cases. The specialist will also provide guidance and resolve issues for network providers and clients in the Workers' Compensation and No-Fault sectors. Collaborating closely with both providers and clients is essential, especially when disputes arise. A thorough understanding of provider and company-specific policies and procedures is crucial. This role requires partnership with Provider Contracting, Sales, Medical Management, and Operations to identify and address provider-related concerns. The Claims Support Specialist reports directly to the Casualty Support Manager.
The ideal candidate will have the opportunity to contribute to the structuring of this essential team, which is integral to delivering high-quality healthcare services.
This job description is intended to outline the primary duties and responsibilities associated with this role. Responsibilities may evolve, and additional tasks may be assigned as necessary.
Key Responsibilities
- Gather information from claimant representatives, healthcare providers, or hospitals; confirm claimant case status and provider participation.
- Establish cases within the Medical Management system following departmental workflows and guidelines.
- Assist Nurse Case Reviewers with non-clinical inquiries (e.g., requesting clinical documentation from providers, obtaining necessary forms, and verifying work status).
- Perform data entry for essential case demographics, including the transcription of clinical data.
- Manage incoming group calls and engage with employers, employees, physicians, and insurance adjusters to obtain timely information regarding medical status and required care.
- Coordinate medical appointments for members with in-network facilities and providers, ensuring member attendance.
- Maintain and update all activity logs within specified timeframes.
- Ensure accurate verification of claimant cases; create, scan, fax, mail, and upload necessary correspondence and documentation.
- Comply with established quality assurance standards and all company policies and procedures.
- Educate providers on current policies, trends, and relevant information affecting their participation in the network.
- Act as a liaison for interpreting No-Fault and Workers' Compensation contracts.
- Address inquiries related to provider contracts or claims issues.
- Investigate provider contract/claim issues raised by providers or clients and conduct claims analysis.
- Maintain a database for provider issues and generate detailed reports as required.
- Collaborate with management to develop short- and long-term strategies that enhance provider services.
- Participate in Ad-Hoc projects and support departmental initiatives as needed.
- Document and discuss any concerns, complaints, or issues with the direct supervisor.
- Exhibit a compassionate, understanding, and positive demeanor with all clients and colleagues.
Essential Qualifications
- Proficient in PC applications (Excel proficiency is essential).
- Strong organizational and problem-solving abilities.
- Familiarity with the IMPACT claims system is advantageous.
- Notary License is a plus.
- Ability to maintain professionalism under pressure.
- Capable of working independently as well as collaboratively.
- Minimum of one year of relevant experience.
- Bachelor's degree or equivalent experience preferred.
- Bilingual candidates are preferred but not required.
- Previous experience in case management related to insurance claims is beneficial.
- Strong skills in reviewing medical records.
- Understanding of medical terminology is advantageous.
- Current knowledge of workers' compensation and legislative matters is a plus.
- Familiarity with the health insurance industry, products, and services.
- Knowledge of claims processing and related procedures.
- Strong follow-up, negotiation, and influencing skills.
- Able to manage multiple complex issues effectively.
About Brighton Health Plan Solutions, LLC
At Brighton Health Plan Solutions, we are dedicated to enhancing the accessibility and delivery of healthcare. Joining our team means becoming part of a diverse and inclusive culture that values respect and encourages individuality. We empower our employees to bring their authentic selves to work, leveraging their unique talents.
Brighton Health Plan Solutions collaborates with self-insured employers, Taft-Hartley Trusts, healthcare systems, providers, and other third-party administrators to address contemporary healthcare challenges through innovative and flexible administration services. Our extensive experience in health plan management, proprietary provider networks, and advanced technology platform enable us to offer customizable solutions that enhance member experiences, improve health outcomes, and help achieve healthcare objectives.
Company Mission
Transform the health plan experience by delivering exceptional products and services to our partners.
Company Vision
Redefine healthcare quality and value by aligning the interests of our partners in unique and impactful ways.
DEI Purpose Statement
At BHPS, we encourage all team members to embrace their authentic selves at work, celebrating the diversity of experiences and perspectives. We are committed to fostering a culture that prioritizes diversity, inclusion, and a sense of belonging at every level.
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