Claims Management Specialist

1 week ago

Fort Wayne, Indiana, United States EPIC Brokers Full time
Claims Management Specialist

Location: Remote

The primary objective of this role is to oversee the administration of Specific and Aggregate claim submissions, along with tracking reimbursements as funds are processed. This position involves identifying participants in Large Case Management and directing referrals to appropriate external professionals. Effective communication and documentation of large claimant statuses, invoices, fees, and savings are essential. Responsibilities also include establishing transplant contracts and collaborating with Value Added Service vendors. Notifications to reinsurers are to be sent out at a rate of 50%. Additionally, documenting inpatient and pre-approved services within the pre-authorization module and managing Independent Medical Reviews are key tasks. Support for auditing and customer service functions may also be required.

Key Responsibilities:
  • Ensure timely submission of Specific and Aggregate Claims. Maintain organized shared folders by Plan Year, Client, and Claimant. Coordinate the release of electronic checks with the Accounting department. Track reimbursement requests using an Excel spreadsheet and provide follow-up as necessary.
  • Large Case Management: Enter referrals into the system within 48 hours of notification. Submit monthly reports within 4 days of receipt and process invoices within 5 days. Handle incoming inquiries related to Case Management and file 50% notifications monthly.
  • Pre-Authorization Module: Conduct research and respond in compliance with Health Care Reform Laws. Enter all precertifications and prescription overrides within 48 hours of receipt.
  • Independent Medical Reviews: Dispatch reviews in accordance with Health Care Reform laws and document conclusions.
  • Provide backup support for Customer Service phone duties.
  • Generate monthly reports and send correspondence as necessary for Continuity of Care. Assist with claim negotiations related to the No Surprises Act as required.
Qualifications:
  • High School Diploma/GED with 8-10 years of experience; or an Associate's degree with 5-8 years of experience; or a Bachelor's degree with 2-5 years of experience; or a Master's/MBA with 0-2 years of experience.
  • Relevant education or certification in Medical fields; knowledge in Medical & Dental Terminology, Anatomy & Physiology.
  • Experience in Claims Processing and/or Medical Review is mandatory.
  • Familiarity with Reinsurance Stop Loss and Aggregate filing is preferred.
  • A minimum of 8 years of relevant experience is required.
Essential Skills:
  • In-depth knowledge of insurance industry standards.
  • Strong understanding of anatomy and physiology.
  • Proficiency in Microsoft Office Suite (Word & Excel).
  • Excellent analytical skills.
Why Choose EPIC?
  • Recognized as a leading Global Broker by AM Best.
  • Ranked among the Top 100 Largest U.S. Brokers by Business Insurance.
  • Comprehensive benefits package including 401K matching, generous time off, flexible work options, and various insurance plans.
EPIC values diversity in all its forms, fostering a workplace where every employee feels welcomed, valued, and respected. We believe that diversity fuels innovation and that creating an inclusive environment empowers our team to deliver exceptional outcomes for our clients.

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