Claims Specialist

Required Skills & Experience

• Have knowledge of group health plan philosophy and Department of Labor health claim regulations.

• Knowledge of medical benefits, medical terminology and coding, and coordination of benefits rules.

• Knowledge of basic math related to claims adjudication.

• Excellent analytical and research abilities.

• Must be able to communicate effectively verbally and in writing with participants, providers, and medical consultants.

• Ability to use sound judgment in exercising discretion under general supervision and within the parameters of policy set by management, seeking guidance on policy when appropriate.

• Ability to work independently with minimal supervision.

Job Description

The Claims Review Coordinator is responsible for the investigation, documentation and resolution of denied claims in compliance with State/Federal law, rules, and guidelines. The Claims Review Coordinator will perform research and utilize extensive claims knowledge to respond to inquiries and interpret plan/policy provisions.

This position interacts with the Health Plan staff, Plan participants, business managers, health care providers, medical insurance companies and related governmental agencies, and medical consultants. In addition to daily interaction with the Department Manager and Assistant Manager, this position also interacts with Executive Management whenever necessary.

ESSENTIAL FUNCTIONS:

Work independently using discretion and independent judgment under the general supervision of the department manager and within broad parameters of policy established by management:

• Write determination letters regarding the outcome of non-clinical reviews/claim denials and send to the applicable participant/provider. Correspond with participants and providers via email and telephone.

• Research incoming correspondence related to claim denials and determine what next steps need to be taken.

• Assist with research to advise management on medical claims issues and assist with developing guidelines for use by the examiners or Participant Services Representatives when necessary.

• Assist Appeals Coordinator with preparation of Benefits Committee appeal cases.

• Develop guidelines for examiners to use in evaluating whether certain types of claims may require review and other medical claims issues.

• Work with legal counsel on cases as directed by Management.

• Provide guidance to Participant Services Representatives on calls regarding medical claims issues.

• Recommend changes to management on Health Plan language for medical benefits.

• Regular, predictable, and reliable attendance is required.

• Ability to accept direction and developmental guidance from supervisor.

• Ability to work effectively with individuals at all levels.

• Perform other duties as assigned.