Claims Specialist

Claims Specialist 

Bronx, NY  

Schedule: M-F, 8:30am to 5:30pm  

Work Location: Hybrid 

Assignment Length: Undetermined, potential for Direct Hire 

FlexStaff is seeking a Claims Specialist for our client, a non-profit healthcare organization providing home and community-based healthcare and services for the elderly. This role is responsible for supporting department operations related to provider communication, pending claim review, reporting, auditing, and oversight activities.  

Responsibilities:  

• Responsible for reviewing claims processed by the outside vendor, including resolving provider appeals/disputes.  

• Compiles claim reports 

• Investigates suspense conditions 

• Communicates and follows up with a variety of internal and external sources 

• Attends JOC meetings with providers as appropriate 

• Ensures that refund checks are logged and processed 

• Generates routine daily, monthly and quarterly reports 

• Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor 

• Analyzes patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditions 

• Other related duties as assigned by the supervisor  

Qualifications:  

• Bachelor’s degree 

• Certified Professional Coder, a plus 

• Eight or more years of insurance experience within a healthcare setting, preferred 

• Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system 

• Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS 

• Knowledge of MLTC/ Medicaid/Medicaid benefit, Member (Subscriber) enrollment & billing, Utilization Authorizations, Provider Contracting

Additional Salary Detail 

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member’s base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).