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Claims Support Specialist I
2 months ago
Position: Claims Support Specialist I
Location: Remote
Contract Duration: 5 months (Potential for permanent placement)
Work Schedule: Monday to Friday, 8:30 AM - 4:00 PM
Note:
- Preferred Qualifications: Experience in claims processing; effective time management; capability to work autonomously; strong research abilities; excellent communication skills; reliability; adeptness in managing time; capacity to operate independently.
Key Responsibilities:
- Manage responses to standard inquiries. Identify and rectify incorrectly processed claims, executing necessary adjustments and related reprocessing actions. Review and adjudicate claims and/or non-medical appeals. Assess whether to return, deny, or approve claims in accordance with organizational policies and procedures.
- 40% Address written and/or telephone inquiries following established desk procedures, ensuring compliance with contract standards and objectives for timeliness, productivity, and quality. Document inquiries accurately. Identify incorrectly processed claims and execute adjustments and reprocessing actions in line with departmental guidelines.
- 40% Analyze and process claims and/or non-medical appeals according to business regulations, internal standards, and examination guidelines. Input claims into the claims system after verifying the accuracy of procedure and diagnosis codes. Ensure claims are processed in alignment with established quality and production benchmarks.
- 20% Recognize complex complaints and inquiries that cannot be resolved through standard desk procedures and escalate these to a lead or manager for resolution. Promptly identify and report suspected fraudulent activities and system errors to the appropriate departments.
Required Skills and Competencies:
Excellent verbal and written communication skills. Strong customer service orientation. Proficient spelling, punctuation, and grammar skills. Basic proficiency in business mathematics. Ability to manage confidential or sensitive information with care. Required Software and Tools: Proficiency in Microsoft Office. Work Environment: Standard Office Environment.
Educational Requirements:
Minimum Education: High School Diploma or equivalent. Minimum Work Experience: 1 year in claims/appeals processing, customer service, or a related support area, or a Bachelor's Degree in lieu of work experience.
