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Claims Specialist
2 months ago
Location:
Doral, FL
Position Overview:
Sentara Health is seeking a Claims Specialist to join our team, focusing on the Florida market.
This role offers a hybrid work arrangement, allowing for both in-office and remote work.Role Responsibilities:
The Claims Specialist will manage centralized appeal processing tasks for healthcare providers, including physicians, facilities, and ancillary services. The individual will identify issues related to claims and propose effective solutions.
Key Duties:
• Review and make administrative determinations on claims submitted by providers and other sources.
• Adjust claims based on reviews and administrative decisions.
• Interpret policies and procedures to accurately adjudicate various claims.
• Conduct thorough research and system inquiries to gather claim-related information.
• Undertake special projects related to claims review challenges.
• Adjust claims as necessary, utilizing appropriate information.
• Identify and communicate issues related to systems, providers, and adjudication to enhance first-time claim processing accuracy.
• Recognize providers requiring claims experience evaluations.
• Understand and apply HIPAA compliance regulations when handling Protected Health Information.
• Collaborate with other departments to resolve issues for members and providers.
Adhere to company policies and procedures, including dress code and punctuality as they pertain to work hours, breaks, and lunch periods.
Additional duties may be assigned by management as needed.Qualifications:
• Associate's degree required; Bachelor's degree in business or a related field preferred.
• 3-5 years of experience in a complex managed care environment, with a focus on claims, pricing, and/or benefits in healthcare.
Previous experience in auditing or system configuration is preferred.Preferred Skills:
• Strong verbal and written communication abilities.
• Excellent analytical and interpretative skills.
• Outstanding organizational capabilities.
• Effective problem-solving skills, with the ability to manage both simple and complex tasks.
• Detail-oriented, capable of adapting to various workflows, multiple tasks, deadlines, and shifting priorities.
• Knowledge of Medical Coding, including CPT, HCPCS, ICD-10, and DRG Codes.
• Familiarity with HRP, MACESS, or similar software systems.
• Proficiency in Microsoft Office Suite (Word, Excel, Access).
Employee Benefits:
• Comprehensive Medical, Dental, and Vision Insurance.
• Paid Annual Leave and Sick Leave.
• Flexible Spending Accounts.
• Retirement plans with matching contributions.
• Supplemental insurance options, including legal, life insurance, and AD&D.
• Employee perks program offering discounts on various services and products.
• Opportunities for career advancement within the organization.
As a leading employer, Sentara Health is dedicated to providing quality healthcare and fostering an environment of training, development, and growth.
Job Summary:
The Claims Specialist will oversee all aspects of customer service related to member acquisition and retention for Sentara Health Plan, Inc. This includes managing group information, processing claims, and engaging with members, providers, and employers.
Special Projects:
Responsibilities may include initial reviews and analyses, recommendations, and participation in research team reports, provider site visits, and new technology testing as assigned.
Qualifications:
• High School Diploma or equivalent required.
• Certified Professional Coder (CPC) certification from the American Academy of Professional Coders (AAPC) is preferred.
• Experience in administrative roles, customer service, and health plan claims disbursements.
Skills:
• Proficiency in Microsoft Excel and Word.
• Project management and technology/computer skills.
• Typing speed of 30+ WPM and strong writing abilities.
Sentara Healthcare values diversity and inclusiveness within its workforce, ensuring it reflects the communities it serves. In support of our mission to improve health every day, we maintain a tobacco-free environment.
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