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Claims Processing Specialist

2 months ago

Greensboro, North Carolina, United States Care N Care Insurance Company of North Carolina Full time
Job Overview

Position Summary:

The Claims Processing Specialist will report directly to the Director of Operations – Provider Services and Claims. This role is pivotal in fulfilling Care N Care Insurance Company's mission by collaborating closely with our partners. The focus will be on ensuring that the design, configuration, and adjudication of claims align with the company's standards for handling, productivity, and quality.

Key Responsibilities:

  • Continuously assess the status of claims and generate necessary inventory reports for management evaluation.
  • Oversee the performance metrics of claims adjudication and production; implement timely corrective measures to achieve favorable outcomes.
  • Review and coordinate with TPA partners and internal teams regarding updates to coding, CMS guidelines, and plan modifications affecting claims.
  • Ensure compliance with efficiency and service level objectives, including volume, processing speed, accuracy, and other relevant metrics.
  • Act as a liaison among TPA/BPO partners, internal teams, and external organizations, providing leadership in claims, provider disputes, and benefit administration.
  • Offer guidance and support to claims and operations staff in resolving claim-related issues, emphasizing root cause analysis.
  • Collaborate with partners and TPA/BPO operations administrators to formulate corrective action plans for claims and benefits challenges.
  • Assist internal team members in addressing daily operational issues.
  • Work cross-departmentally to identify and rectify problems leading to incorrect claims payments.
  • Support management in pinpointing and coordinating training needs related to claims and provider dispute resolution.
  • Prioritize issues raised by TPA/BPO, internal teams, and partner representatives, tracking progress toward resolution.
  • Compile, analyze, and act upon claims management reports.
  • Identify trends and issues within Claims, Provider Relations, and Medicare Operations, recommending actionable solutions and ensuring timely communication.
  • Draft and monitor inquiries regarding claim system configurations to address systemic payment issues.
  • Create and present operational metrics and dashboards for tracking claims, provider disputes, and benefits performance.
  • Serve as the project coordinator for the configuration and setup of the core claims platform and benefit structure within the TPA/BPO system, ensuring accuracy and completeness.
  • Verify that all benefit components are correctly established within the claims payment system, in accordance with plan materials.
  • Ensure that desk-level procedures and pay policies are finalized and compliant with plan requirements.
  • Develop a comprehensive understanding of claims processing capabilities and limitations within TPA/BPO systems, providing recommendations to meet plan specifications.
  • Participate in various committees and attend required meetings.
  • Perform additional duties and projects as assigned.

Qualifications:

Education: Associates Degree or equivalent experience of 3+ years in claims processing.

Experience:

3 – 5 years of experience in claims processing, claims system configuration, or benefit configuration functions, with a focus on Medicare Advantage Plans.

Preferred Qualifications:

Bachelor's degree in healthcare, business, or a related field; Certified Professional Coder (CPC); 3 – 5 years of experience in a Medicare health plan, managed care organization, or third-party administrator.

Other Requirements:

Annual Flu Shot.

Skills and Abilities:

Required:

In-depth knowledge of benefit designs, structures, medical policies, and their implications on claims processing.

Extensive experience in operations, service, and process engineering implementations.

Exceptional written, analytical, and oral communication skills.

Strong active listening and communication abilities.

Advanced analytical and problem-solving skills.

Ability to work independently and effectively present information to peers and management.

Preferred:

Intermediate proficiency in Microsoft Word, Excel, and Access.

Entrepreneurial mindset focused on enhancing health plan operations and implementations.

Physical Requirements:

Ability to exert up to 10 lbs. of force occasionally and negligible force frequently. Primarily sedentary work with occasional walking or standing.

About Care N Care Insurance Company:

Care N Care Insurance Company is an equal opportunity employer, committed to diversity and inclusion in the workplace.