TITLE: Medical Claims Specialist

EDUCATION: Must have Associate's or Bachelor's degree in healthcare or business related field 

DURATION: long term open ended contract (includes benefits, sick time, 401k, weekly pay)

LOCATION: Remote (must be able to work EST)

HOURS: full-time 40 hours, Monday - Friday. Flexible start time between 7am-9am EST
Operating Hours: 7am-5:30pm EST

PAY: $22-25/hr DOE

GENERAL RESPONSIBILITIES: This individual will coordinate activities critical to the successful completion of clinical studies and review projects. They will support programs by monitoring requests, liaising with clinical partners, managing provider and contractor interactions, tracking deliverables and deadlines, and develop project frameworks to support interdisciplinary and interagency communications.

DUTIES:

1. Act as point-of-contact for appeal/dispute adjudication programs.

2. Liaise with healthcare plans, providers, patients, and clients to coordinate requests, correspondence, and submission of case documentation, as necessary.

3. Monitor appeal/dispute status and communication received on client portals.

4. Conduct initial eligibility reviews and recommend course of action to internal team and department management.

5. Track and assign cases using commercial off-the-shelf and custom software applications.

6. Review and provide case documentation to assigned billers/coders, nurses, physicians and clinicians internal teams and key stakeholders to facilitate clinical and coding reviews.

7. Monitor and measure key performance indicators including, but not limited to, timeliness, adherence to quality and accuracy standards, and deadlines for contract deliverables.

8. Identify barriers and roadblocks in work processes, recommend solutions to solve problems, and execute approved solutions.

9. Routinely present case/project status in huddles and scrums while using an agile, iterative approach to implementation and data presentation.

10. Schedule regular team status meetings and record decisions (e.g., assigned tasks and next steps).

11. Prepare billing invoices at conclusion of cases, submit to the Finance department, and liaise with accounting to track and trend payments.

12. Mentor and train new staff, at all levels, on process steps and case progression.

13. Other activities may be deemed necessary.

QUALIFICATIONS:

1. Knowledge and experience with collaborative project management software, electronic documents, and design.

2. Ability to problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.

3. Excellent written and verbal skills including phone manner.

4. Ability to work independently with little supervision.

5. Ability and desire to be flexible, innovative, and creative while multitasking. Ability to meet deadlines in time sensitive environment

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients