Claims Specialist - Remote

Overview

The Claims Specialist serves Medicare insurance customers by determining insurance coverage, examining and resolving medical claims, documenting actions, maintaining quality customer services, and ensuring legal compliance.

In Short

• Responsible for processing claims in accordance with production, timeliness and quality standards.
• Participates with other health plan departments in the resolution of claims issues across department lines.
• Ensures claims are processed in compliance with governmental and accrediting agency regulations.
• Provides timely and accurate claims payment and responds to member and provider inquiries.
• Develops strong intradepartmental relationships to ensure clear communication.
• Follows departmental policies and procedures regarding claims adjudication.
• Identifies and reports potential fraudulent claims practices.
• Follows HIPAA compliance guidelines to protect member health information.
• Drives the HealthAxis culture through values and customer service standards.
• Maintains positive relationships through effective communication.

Requirements

• Understanding of hospital and/or physicians’ contracts and knowledge of pricing for medical claims.
• Excellent oral and written communication skills.
• Able to read and interpret documents and calculate figures.
• Proficient in MS Office with basic computer skills.
• Excellent customer service skills.

Benefits

• A people-first approach shaping the work environment.
• Commitment to creating a vibrant and human-centric environment.
• Opportunities for engagement and empowerment.
• Focus on collaboration and teamwork.
• Support for personal and professional development.