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Healthcare Claims Specialist

2 months ago

Cleveland, Ohio, United States Everstaff Full time
Job Overview

EverStaff is seeking a skilled Medical Claims Adjuster to join our team. This role involves the meticulous review, investigation, and processing of medical claims to guarantee precise payments in accordance with policy stipulations.

Compensation
  • Salary Range: $50,000 - $65,000
Benefits Offered:
  • Comprehensive Medical, Dental, and Vision insurance
  • 401K retirement plan
  • Paid Time Off (PTO)
  • Life insurance coverage
  • Potential for bonuses
  • Profit-sharing opportunities
Key Responsibilities:
  • Thoroughly assess and verify medical claims for accuracy and completeness, ensuring adherence to policy guidelines, insurance laws, and organizational protocols.
  • Conduct detailed investigations of claims by collecting necessary medical documentation, invoices, and supporting evidence. Evaluate medical reports and billing codes to ascertain coverage and liability.
  • Decide on the appropriate resolution or denial of claims based on the investigation findings, policy coverage, and legal requirements. Generate comprehensive reports and documentation to substantiate claim decisions.
  • Effectively communicate with policyholders, healthcare providers, and other relevant parties to gather information, clarify coverage decisions, and address any issues related to the claims process.
  • Ensure compliance with all state and federal regulations, as well as company policies and procedures, in the handling of claims. Stay informed about industry developments and legal changes.
  • Accurately document all claims-related activities, including notes on discussions, decisions made, and follow-up actions. Maintain organized and secure records for each claim.
  • Deliver exceptional customer service to policyholders and healthcare providers by addressing inquiries, resolving disputes, and ensuring a positive experience throughout the claims process.
  • Collaborate closely with the legal team, fraud investigators, and other departments as necessary to manage complex claims, identify potential fraud, and ensure proper claim resolution.
Qualifications:
  • Bachelor's degree in a relevant field (e.g., healthcare, insurance, business) preferred, or equivalent professional experience.
  • 2-4 years of experience in medical claims adjusting, insurance, or a related field.
  • Proficiency in healthcare billing codes (ICD, CPT) and medical terminology is essential.
Skills Required:
  • Strong analytical and problem-solving capabilities
  • Excellent written and verbal communication skills
  • Proficient in MS Office (Word, Excel, Outlook) and claims processing software
  • Attention to detail and accuracy
  • Ability to work independently and collaboratively within a team
  • Strong organizational and time-management skills

All qualified applicants will receive consideration for employment without regard to race, color, religion, ethnicity, national origin, sex, gender identity, sexual orientation, disability status, protected veteran status, or any other protected status under the law. EverStaff is an equal opportunity employer (M/F/D/V/SO/GI).