Medical 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, auto, workers' compensation, and property damage. 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.

Duties:

• Manage and coordinate all aspects of insurance claims processing, including auto estimating, medical documentation review, and construction inspection 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, auto repair shops, 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 negotiation, auto service management, water damage restoration procedures, and clerical processes.

Qualifications:

• Proven experience in insurance claims management with a strong understanding of workers' compensation, auto insurance, medical billing, and construction inspection processes.
• 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.
• Familiarity with auto estimating software, auto body repair procedures, automotive repair processes, and auto restoration practices.
• 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.
• Mechanical knowledge related to automotive service management or water damage restoration is a plus.
• 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 residents while advancing your career in a dynamic environment committed to excellence!