What are the responsibilities and job description for the Claims Specialist position at Winston Staffing Services?
The Claims Resolution Specialist plays a critical role in the successful adjudication of claims and appeals within our organization. This position requires a highly organized and detail-oriented individual with strong communication and problem-solving skills. The Specialist will collaborate with internal and external stakeholders to ensure timely and accurate resolution of claims, while adhering to all relevant regulations and guidelines.
Responsibilities:
- Act as the primary point of contact for all aspects of claim appeals and disputes.
- Conduct thorough initial eligibility reviews and recommend appropriate courses of action.
- Liaise effectively with healthcare plans, providers, patients, and clients to gather necessary information and facilitate claim resolution.
- Monitor claim status, track key performance indicators (KPIs), and identify potential areas for improvement.
- Analyze claim data to identify trends and patterns, and develop strategies to mitigate potential issues.
- Prepare and maintain accurate and up-to-date documentation for all claims.
- Collaborate with internal teams (e.g., billing, coding, medical review) to ensure timely and accurate claim adjudication.
- Identify and resolve claim-related issues proactively, escalating complex cases as needed.
- Contribute to process improvement initiatives and ensure compliance with all relevant regulations.
- Provide support and guidance to junior team members as needed.
Qualifications:
- Bachelor's degree in Healthcare Administration, Business Administration, or a related field.
- 2 years of experience in healthcare claims processing, appeals, or a related field.
- Strong understanding of healthcare regulations and reimbursement methodologies.
- Excellent communication and interpersonal skills, both written and verbal.
- Proficiency in Microsoft Office Suite and other relevant software applications.
- Strong analytical and problem-solving skills with the ability to work independently and as part of a team.
- Detail-oriented with a high degree of accuracy and the ability to meet deadlines.
Preferred Qualifications:
- Experience with electronic health records (EHR) systems.
- Knowledge of industry-standard claims processing software.
- Experience with data analysis and reporting.
Key Competencies:
- Communication
- Collaboration
- Problem-solving
- Analytical skills
- Time management
- Organization
- Attention to detail
Salary : $26 - $28
