Claims Specialist

Company Overview:

Certus Healthcare Management proudly owns and operates a network of 17 communities across Ohio and Michigan, serving both rural and urban populations. Our mission is to deliver personalized, family-focused care that enhances the quality of life for our residents and their families, fostering an environment where everyone’s voice is heard and valued.

Overview:

We are seeking an energetic and detail-oriented Medical Insurance Claims Specialist to lead our claims processing team. In this pivotal role, you will oversee the entire claims lifecycle, ensuring accurate, efficient handling of insurance claims related to health, workers compensation and other medical insurance claims. Your expertise will drive fraud prevention, risk analysis, and effective negotiation strategies to optimize claim outcomes while maintaining exceptional service standards.

This position will work out of our corporate office located in Mayfield Heights, Ohio. Typical schedule for this position is 9am to 5pm, Monday through Friday.

Duties:

• Manage and coordinate all aspects of insurance claims processing, including medical documentation review, and reports.
• Lead investigations into potential fraud cases by utilizing fraud detection tools and analysis skills to identify suspicious claims.
• Oversee risk management procedures by analyzing claim data to identify trends and implement preventative measures.
• Collaborate with underwriters, medical professionals, and legal teams to facilitate accurate claim assessments.
• Ensure compliance with industry standards such as ICD-9/10 coding, CPT coding, HCPCS codes, and Medicare/Medicaid regulations.
• Develop and implement service writing strategies that enhance customer satisfaction while safeguarding company interests.
• Provide training and mentorship to claims staff on best practices in claims processing and negotiation

Qualifications:

• Proven experience in insurance claims management with a strong understanding of workers' compensation, medical billing and processing.
• Demonstrated expertise in negotiation skills and risk analysis techniques.
• Knowledge of medical terminology, ICD coding (ICD-9/10), CPT coding, HCPCS codes, and medical documentation standards.
• Strong organizational skills with the ability to manage multiple claims efficiently under tight deadlines.
• Analytical mindset with proficiency in financial software and insurance verification systems.
• Excellent communication skills to liaise effectively with internal teams and external partners.

Join us as a Medical Insurance Claims Manager where your expertise will shape a seamless claims experience for our staff and residents while advancing your career in a dynamic environment committed to excellence!