Claims Specialist

Position Overview

We are looking for an organized and detail-focused Claims Specialist to facilitate the execution of clinical review and appeal/dispute adjudication programs. This role acts as a crucial intermediary among healthcare plans, providers, patients, and internal clinical teams, ensuring timely and accurate processing of claims and appeals in line with contractual terms.

Key Responsibilities

• Serve as the main contact point for appeal and dispute adjudication initiatives.
• Manage communication, documentation, and requests between healthcare entities, patients, clients, and internal teams.
• Track updates on appeals and disputes via client portals and communication platforms.
• Perform eligibility assessments and provide recommendations to internal teams and leadership.
• Oversee claims and case assignments using both commercial and proprietary software.
• Distribute documentation to billing, coding, clinical, and physician teams to support reviews.
• Monitor key metrics such as timeliness, accuracy, quality standards, and contract compliance.
• Identify process challenges and propose, then implement, improvements.
• Report project and case progress in team meetings and agile scrums.
• Organize team meetings, document action items, and ensure task completion.
• Generate billing invoices post-case completion and collaborate with Finance and Accounting for payment tracking.
• Provide mentorship and training for new team members regarding workflows and processes.
• Carry out additional projects and duties as assigned.

Candidate Qualifications

• Associate's or Bachelor's degree in Healthcare Administration, Business, Management, Digital Studies, or related field preferred.
• At least two years’ experience in healthcare administration, claims processing, insurance appeals, or medical billing.
• Proficient in project management and electronic document management software.
• Strong analytical thinking and problem-solving abilities, coupled with effective cross-team collaboration skills.
• Excellent communication skills, including professional telephone etiquette.
• Capable of working independently and handling multiple tasks simultaneously.
• Highly organized, adaptable, and flexible with a proactive approach.
• Ability to meet deadlines and excel in fast-paced, time-sensitive environments.

Preferred Skills and Experience

• Experience in medical claims, appeals, utilization management, or dispute resolution.
• Understanding of healthcare operations, medical documentation, coding, and provider liaison.
• Knowledge of payer systems and claim adjudication processes in healthcare.
• Experience working within agile and project-focused teams.

Why Join Us?

This role offers a chance to be part of a collaborative healthcare team aimed at enhancing claims accuracy and clinical review efficiency. You will contribute to impactful outcomes by ensuring smooth case management and working closely with healthcare professionals and stakeholders.