Medical Claims Specialist - Remote

Claims Specialist

The Claims Specialist will assist in reviewing, processing, and coordinating claims accurately in accordance with the program requirements while ensuring compliance and enhancing client relationships.

In this job, you will :

• Maintain ongoing knowledge of program requirements
• Analyze and process claims for accuracy, eligibility, and benefits coverage
• Retain and strengthen relationships with clients and members
• Assist members in managing and resolving reimbursement issues related to medical services and covered expenses that are medically necessary
• Correspond to verify if the amounts are related to the claim
• Develop and maintain a working knowledge of medical bill processing, procedures, and supporting systems
• Adhere to quality assurance objectives and goals
• Develop and maintain a working knowledge of all support systems to ensure ever increasing client value and Rising's returns from administration services
• Research and utilize problem-solving skills to resolve claim discrepancies, errors, or incomplete information by communicating with providers, members, or internal departments
• Keep management updated on activities, issues, and developments
• Document all claims decisions and communications with members in the system accurately and timely
• Ensure strict confidentiality of all medical information and adhere to privacy regulations and company policies
• Special projects as assigned by management

Reports to : Program Manager