Medical Claims Specialist

Job Title: Claims Specialist

**We are open to any admin experence as long as you have a Bachelor's or advanced degree in healthcare, business, management, digital studies, or a related field.**

General Responsibilities:

The Claims Specialist will coordinate activities crucial to the successful completion of clinical review projects. This individual will support various programs by monitoring requests, managing interactions with clinical partners, tracking deliverables and deadlines, and developing project frameworks to streamline interdisciplinary and interagency communications.

Key Duties:

• Serve as the primary point of contact for appeal and dispute adjudication programs.
• Liaise with healthcare plans, providers, patients, and clients to coordinate requests, correspondence, and submission of case documentation as needed.
• Monitor appeal and dispute status, as well as communication received through client portals.
• Conduct initial eligibility reviews and recommend courses of action to internal teams and department management.
• Track and assign cases using commercial off-the-shelf and custom software applications.
• Review and distribute case documentation to assigned billers/coders, nurses, physicians, clinicians, internal teams, and key stakeholders to facilitate clinical and coding reviews.
• Monitor and measure key performance indicators, including timeliness, adherence to quality standards, and contract deliverable deadlines.
• Identify barriers and roadblocks in work processes, recommend solutions, and implement approved actions.
• Present case and project status regularly in huddles and scrums using an agile and iterative approach to implementation and data presentation.
• Schedule regular team status meetings and document decisions, assigned tasks, and next steps.
• Prepare billing invoices at the conclusion of cases, submit to the Finance department, and collaborate with accounting to track and trend payments.
• Mentor and train new staff, at all levels, on process steps and case progression.
• Perform other duties as assigned or required.

Qualifications:

• Bachelor's or advanced degree in healthcare, business, management, or digital studies.
• Proficiency with collaborative project management software, electronic documents, and design tools.
• Strong problem-solving skills with the ability to work effectively in a team environment.
• Excellent written and verbal communication skills, including a professional phone manner.
• Ability to work independently with minimal supervision.
• Highly adaptable, innovative, and capable of multitasking in a dynamic work environment.
• Proven track record of meeting deadlines in time-sensitive situations.

Education & Experience:

• Bachelor's or advanced degree in healthcare, business, management, digital studies, or a related field.
• 2 years of collaborative project support preferred; however, new graduates will be considered.

Work Options:

This position offers a hybrid office/remote work option.