claim processing specialist

Blue Shield of California

<div>Your Role 
The Medi-Cal Operations team is responsible for ensuring claims are processed accurately and timely. The Claims Processor, Specialist will report to the Medi-Cal Operations Supervisor. In this role you will be responsible for interfacing with other departments and vendors involved in the Claims process and will also serve as the primary point of contact for priority claim cases. 
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow &ndash; personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.</div>
 <div>Your Work 
In this role, you will:
<ul><li>Handle most complex activities including backup for all areas of claims processing
</li><li>Actively participate in projects
</li><li>Handle escalated issues independently
</li><li>Mentor experienced team members
</li><li>Assist with training when needed
</li><li>Collaborate with peers, staff in other department's vendors, and Management to improve processes and department work quality.
</li><li>Must be able to work in a fast-paced environment with minimal supervision
</li><li>Read and interpret documents such as provider contracts procedure manuals, various reports, division of financial responsibility matrix</li></ul></div>
 <div>Your Knowledge and Experience 
<ul><li>Requires a high school diploma or GED
</li><li>Requires at least 7 years of experience
</li><li>Minimum of 3 years of experience in claims processing and/or auditing experience in a manage care setting required
</li><li>Experience examining multiple claim types in the Medi-Cal/Medicare environment preferred
</li><li>Knowledge of medical claims regulatory guidelines such as AB1455 and Medicare preferred
</li><li>Proficiency in Microsoft Office programs such as Excel, Word and Outlook required 
</li></ul>Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.</div>
 <div>ABOUT THE TEAM 
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
Our Values:
<ul><li>Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul><div>Our Workplace Model
We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
<ul><li>For most teams, this means coming into the office two days per week.
</li><li>Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
</li><li>For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
</li></ul>The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
</div>Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. 
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.</div>

Claims Processor, Specialist

AllCare Management Services

<div>We Are Seeking Qualified Candidates to Join Our Team!
AllCare Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.
Summary of the Position
This position supports claims operations and financial integrity by performing a variety of administrative and department functions related to claims processing, system COB updates, and audit support. Responsibilities include managing Coordination of Benefits (COB) reporting, implementing updates within the EZ-CAP claims system, processing refunds and overpayment recoveries, and assisting with internal and external audit activities, including HSAG, OHA, CMS, and financial audits. The role also involves reviewing claims identified through monitoring reports, ensuring issues are researched and resolved appropriately, and supporting check run activities to help ensure accurate and timely provider payments. This position works collaboratively with all claims staff, finance, compliance, and IT teams to maintain efficient operations and ensure adherence to regulatory and organizational requirements.
Essential Duties 
1. Maintain and update Coordination of Benefits (COB) information, including reporting, verification, and system updates to ensure accurate claims processing 
2. Review, research, and process refund requests and overpayment recoveries, ensuring compliance with contractual, regulatory, and internal policies 
3. Provide departmental support for internal and external audits, including preparation of documentation and data requests for entities such as HSAG, CMS, and financial auditors 
 
Qualifications
Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
Education
High school diploma or general education degree (GED) required. College degree in an applicable field is preferred.
Experience
One to two years related experience and/or training in administrative and/or medical claims processing required. EZ-CAP claim processing system experience is highly preferred.
Certificates, Licenses, and/or Registrations 
This position does not require any certificates, licenses, or registrations. The following certifications are preferred for this job role: 
<ul><li>Certified Professional Coder (CPC)</li><li> 
Certified Clinical Medical Assistant (CCMA)</li><li>Certified Billing and Coding Specialist (CBCS)</li><li>Certified Medical Administrative Assistant (CMAA)</li><li>Certified Coding Specialist (CCS)</li></ul> 

Technical Skills 
<ul><li>Knowledge of and compliance with HIPAA regulations.</li><li>Proficient in data entry and use of claims management systems</li><li>Knowledge of Medicare and Medicaid, procedures, and regulatory requirements</li><li>Basic understanding of medical coding and billing practices</li><li>Strong attention to detail and ability to identify discrepancies or inconsistencies</li><li>Excellent organizational skills and ability to manage multiple tasks efficiently</li><li>Excellent communication skills, both written and verbal, for interaction with internal and external stakeholders</li><li>Exceptional writing, editing, and proofreading skills.</li><li>Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).</li><li>Skilled at breaking a project into definable and measurable tasks and tracking progress to completion.</li><li>Excellent customer service skills to respond appropriately and interact positively with upset customers.</li></ul>
Interpersonal Skills<ul><li>Reliable, confident, and effective in fostering positive relationships.</li><li>Demonstrates accountability, inspires trust, and connects well with colleagues.</li><li>Trustworthy, accountable, and skilled at collaborative engagement.</li></ul>
Language Skills 
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization. 
 
Mathematical Skills
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
Computer Skills
Has advanced basic computer job skills including logging on to systems, ability to communicate by email, ability to compose documents, enter database information, create presentations, download forms, and preserve/backup important data.
Reasoning Ability
Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to work with problems involving a few concrete variables in standardized situations.
Physical Demands &amp; Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate. 
 
<ul><li>The employee must be able to work onsite, as needed.</li><li>The employee can work from a home office, occasionally.</li></ul> 
Company Overview
AllCare Health Website: https://www.allcarehealth.com.
AllCare Health is incorporated as an Oregon Benefit Corporation and has earned the coveted Certified B Corp&reg; status since 2017. As such, AllCare Health considers its impact on community, society, and the environment in all business decisions. We have long recognized the value in social, economic, and environmental concerns of our employees, customers, and community members. (Learn more about B Corps at https://bcorporation.net/about-b-corps)
AllCare Health headquarters are located in Grants Pass in Southern Oregon on the Rogue River, surrounded by mountains, forests, small farms, and breathtaking views. This thriving and energetic community is ideal for families and outdoor enthusiasts, with a temperate Pacific Northwest climate. We enjoy easy access to outdoor sports and recreation, river rafting, fishing, hiking, biking, wineries, outdoor concerts, the world-famous Ashland Shakespeare Festival, the stunning Oregon coast, magnificent redwood forests, pristine beaches, and much more.
The AllCare Health family of businesses is guided by our corporate principles:
Purpose | Working together with our communities to improve the health and well-being of everyone.
Values | Trust, Innovation, Relationships, and Voice.
Vision | Thriving, Inclusive, and Equitable communities.
Brand Promise | Changing Healthcare to Work for You.
AllCare Health is dedicated to building a diverse and authentic workplace centered in belonging and serving our growing community. If you are excited about this open position but your experience does not align perfectly with every qualification in this post, we encourage you to apply anyway or reach out to our human resources department. You may just be the right candidate for this role or others.
If you need accommodations, help in the application process, or wish to receive this job announcement in an alternative format, please call 541-471-4106 and ask for Human Resources.
All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sexual orientation, gender identity, sex, age, protected veteran or disabled status, or genetic information. 
699 - Claims Processing Assistant_March2026.pdf</div>

CLAIMS PROCESSING ASSISTANT

MedStar Health

<div>About this Job:

MedStar Health has an opportunity for a Patient Accounts Specialist to join the Billing team with MedStar's Patient Financial Services. As a Patient Accounts Specialist on the Billing team, you will be responsible for processing daily billing to include review and correction of daily edits to ensure that payments are met in a timely manner and that benchmarks are met. Ensures compliance with Federal regulations. Work must meet QA standards to ensure both departmental and Patient Financial Services benchmarks are met. 
 
We are specifically looking for candidates who have experience with third-party billing and working electronic payer rejections. Strong knowledge of UB04 and/or 1500 forms, the ability to read/interpret an explanation of benefits as well as proficiency in Microsoft Excel. 
Full time, Monday &ndash; Friday, 7am - 3:30pm schedule working on-site at the billing office located in Nottingham, MD. 
Primary Duties:<ul><li>Daily AM Renamer balancing and validation of the 837i and 837p.</li><li>Patient Accounts Specialist productivity</li><li>Electronic claim rejections</li><li>Processing of paper claims with medical records/attachments</li><li>Daily Billing Reconciliation completion</li><li>Monitor and follow up on daily claim holds with weekly reconciliation.</li><li>Processing of daily interrupt processing of Centralize Coding and Revenue Control claim referrals, etc.</li><li>Processing of returned mail</li><li>Processing of assigned billing projects</li></ul> 
Qualifications:<ul><li>High school graduation or equivalent.</li><li>1 year experience in patient accounting, accounts receivable, or related healthcare field, or an equivalent combination of experience and college education in Accounting, Finance or Healthcare Administration.</li><li>Detailed working knowledge and demonstrated proficiency in multiple payers application billing and/or collection processes, including governmental and non-governmental.</li><li>Requires basic working knowledge of UB04 and/or 1500 and Explanation of Benefits (EOB).</li><li>Requires some knowledge of medical terminology and CPT/ICD-10 coding.</li><li>Excellent communication, analytical, interpersonal and organizational skills.</li><li>Proficient uses of hospital registration and/or billing systems and personal computers as well as Microsoft Excel and Word applications. Ability to type 35 WPM</li></ul>
This position has a hiring range of : USD $18.70 - USD $32.72 /Hr.</div>

Patient Accounts Specialist I - Billing

CommunityCare

JOB SUMMARY: 
The Cost Containment Specialist is responsible for ensuring CommunityCare receives appropriate reimbursement of payment on claims. The Specialists will take actions such as identification of outstanding overpayment of claims, collection of claim overpayments, handling third party claim liability, ensuring appropriate coordination of benefits, coordinating transplant claim processing and reporting of reinsurance claims to reinsurer.
 
KEY RESPONSIBILITIES: 
<ul>
<li>Generate and update database of all applicable claims which have refunds due. Run daily reports for future provider payable amounts by line of business.</li>
<li>Access claims and recoup the proper dollar amount. Keep track of claims that cause negative balances and correct them as needed. Enter claim remarks of all recovery attempts and activities.</li>
<li>Communicates with providers regarding outstanding overpayment amounts and keep phone log records of accounts.</li>
<li>Reply to calls and emails in a timely manner. Update recoupment workflow of changes.</li>
<li>Generate reports of recouped dollars by line of business as well as reporting bad debt amounts.</li>
<li>Review and advise examiners on processing of transplant and Centers of Excellence claims.</li>
<li>Monitor, log and track members cases for reinsurance purposes.</li>
<li>Report monthly to finance and self-funded groups status of all active reinsurance members.</li>
<li>Ensure correct application of coordination of benefits for our member population.</li>
<li>Attempt subrogation for claims related to third party liability.</li>
<li>Assist in the negotiation of settlements related to third party liability claims.</li>
<li>Contribute to the creation of a pleasant working environment with peers and other departments.</li>
<li>Consistently learn and adapt to changes related to claims processing, benefits, limits and regulations.</li>
<li>Generate reports and tracking of requests, receivables, savings and volumes.</li>
<li>Interface with various departments regarding cost containment actions.</li>
<li>Assists in researching and solving complex problems related to claim payments.</li>
<li>Perform other job-related duties as assigned.</li>
</ul>
QUALIFICATIONS: 
<ul>
<li>Self-motivated and able to work with minimal direction.</li>
<li>Ability to read and understand claims processing manuals, medical terminology, CPT codes and perform claims processing procedures.</li>
<li>Knowledge of claims processing manuals and health benefit booklets.</li>
<li>Knowledge in the contracted managed care plan terms and rates for multiple lines of business.</li>
<li>Proficient in Microsoft applications.</li>
<li>Ability to perform complex mathematical calculations.</li>
<li>Demonstrated learning agility</li>
<li>Highly attentive to detail.</li>
<li>Ability to work with a variety of individuals at all levels within and outside the company.</li>
<li>Successful completion of Health Care Sanctions background check.</li>
<li>Possess strong oral and written communication skills.</li>
<li>Ability to organize time effectively and set priorities to meet deadlines.</li>
</ul>
EDUCATION/EXPERIENCE: 
<ul>
<li>High school diploma or equivalent required.</li>
<li>Three years related work experience in claims processing, data entry or medical billing. One year of claims processing experience within CommunityCare or another healthcare environment is preferred.</li>
<li>One year of collections experience preferred.</li>
</ul>
CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin

Claims HMO - Cost Containment Specialist 140-1027

Upbound Group

<div><div>Location:
<div>5501 Headquarters Dr, Plano, Texas, 75024, United States of America</div></div><div><div><div><div> 
</div></div></div></div><div><div><div>Claims Specialist &ndash; Corporate Risk &amp; Safety
Location: Plano, TX
Position Summary
The Claims Specialist supports the Corporate Risk &amp; Safety organization by assisting with low‑severity liability and property claims and providing day‑to‑day administrative and coordination support across claims intake, documentation, vendor follow‑up, safety programs, reporting, and insurance activities. This role works closely with internal partners, our Third‑Party Administrator (TPA), and other suppliers to ensure claims and risk processes are completed accurately, consistently, and in alignment with Company standards.
Key Responsibilities:
Liability Claims Management &amp; Oversight<ul><li>
Support intake and setup of General Liability, Auto Liability, Property Damage, and Store Property Loss claims, ensuring required information is captured.</li><li>
Contact internal parties, claimants, plaintiffs, and witnesses involved in a matter.</li><li>
Assist with basic liability and exposure review and escalate higher‑risk matters to team members.</li><li>
Support review of reserve and settlement recommendations from the Third‑Party Administrator (TPA) by confirming documentation and routing items for approval.</li><li>
Review and assess claim files (notes, emails, invoices, and supporting documentation) to audit and ensure claim processing.</li></ul>
Litigation &amp; TPA Coordination<ul><li>
Assist with logging lawsuit notices and coordinating timely reporting and assignment to the TPA and defense counsel.</li><li>
Track litigation matters and review routine status updates for internal stakeholders.</li><li>
Attend claim and litigation calls with TPAs and counsel as needed; capture notes and action items for follow‑up.</li><li>
Support discovery by gathering internal documents, organizing records, and routing draft responses for review.</li></ul>
Property Claims &amp; Financial Support<ul><li>
Manage store property loss and property damage claims, including collecting estimates and coordinating vendor follow‑up.</li><li>
Support processing of claim payments and vendor invoices by validating required documentation and submitting items for approval.</li><li>
Assist with reconciliation support (tracking, documentation, and follow‑ups) related to claim expenses and Risk Management accounts.</li><li>
Respond to routine internal questions by researching claim documentation and escalating complex allocation issues as needed.</li></ul>
Safety &amp; Driver Risk Programs<ul><li>
Support the Motor Vehicle Report (MVR) monitoring program, including reviewing notifications, tracking license issues, and assisting with &ldquo;Do Not Drive&rdquo; agreement administration.</li><li>
Monitor driver license status and follow up until issues are resolved.</li><li>
Support vehicle‑related safety programs, including motorist observation reporting and decal administration.</li><li>
Participate in vehicle safety reviews and ongoing corporate safety initiatives.</li></ul>
Reporting, Analytics &amp; Compliance<ul><li>
Maintain and track reporting related to claim activity, litigation, costs, and trends.</li><li>
Assist with dashboards, leadership presentations, audits, actuarial reviews, and compliance requests by gathering data and preparing materials for review.</li><li>
Maintain internal Risk Management documentation and resources.</li></ul>
Insurance &amp; Vendor Support<ul><li>
Assist with certificates of insurance and policy administration.</li><li>
Support annual insurance renewal processes across liability, property, workers&rsquo; compensation, and specialty programs.</li><li>
Assist with surety bonds and insurance ID cards.</li><li>
Support activities with TPAs, brokers, safety vendors, and outside counsel as requested.</li></ul>
Qualifications:
Required<ul><li>
1&ndash;4 years of experience in claims, insurance, risk management, or an administrative/operations role (internship or related experience accepted).</li><li>
Ability to support claims investigation practices, documentation standards, and vendor coordination processes.</li><li>
Strong organizational skills, with the ability to manage multiple priorities.</li><li>
Proficient in Excel, PowerPoint and other standard business applications.</li><li>
Clear, professional written and verbal communication skills.</li></ul>
Preferred<ul><li>
Associate&rsquo;s or Bachelor&rsquo;s degree in Business, Finance, Risk Management, or related field.</li><li>
Exposure to claims, litigation support, safety programs, or driver risk monitoring.</li><li>
Experience working with service providers (e.g., TPAs, brokers, repair vendors) and strong customer service skills.</li></ul>
Sponsorship:
Applicants must be authorized to work for ANY employer in the U.S. We are unable to sponsor or take over sponsorship of an employment visa at this time.</div></div></div></div><div></div>

Claims Specialist – Corporate Risk & Safety

lonestar

<div>As an Auto Bodily Injury Claims Specialist and embrace a role that offers the thrill of tackling complex cases while championing customer well-being. You'll be empowered to innovate solutions, ensuring clients receive the support they truly deserve. The position's work-from-home flexibility allows you to create your ideal work environment, promoting a healthy work-life balance without sacrificing productivity. Contribute to a fun and energetic team that thrives on high performance and forward-thinking ideas.
Your empathetic approach and problem-solving skills will shine as you build meaningful connections while resolving claims efficiently. With Lonestar, you'll not only advance your career but also make a positive impact in the lives of others. You will be provided great benefits such as Medical, Dental, Vision, 401(k), Life Insurance, Health Savings Account, Flexible Spending Account. Commitment to Training &amp; Development, Competitive Salary, and Paid Time Off. Take the leap and bring excellence and integrity to the forefront of our claims process!<h3 class="jobSectionHeader">
WHAT WOULD YOU DO AS A AUTO BODILY INJURY CLAIMS SPECIALIST</h3>
As an Auto Bodily Injury Claims Specialist at Lonestar, you can expect a dynamic day filled with engaging responsibilities and meaningful client interactions. Each day will involve reviewing and assessing new claims, investigating details, and communicating with policyholders to gather necessary information. You'll collaborate with medical professionals to evaluate claims and determine appropriate compensations, using your problem-solving skills to navigate complex situations.
Your schedule will be Monday to Friday, either from 8 AM to 5 PM or 8:30 AM to 5:30 PM, after training, this position is hybrid (3 days in-office/2 days work from home), allowing you ample time to focus, strategize, and innovate. You'll participate in regular team meetings to share insights, ensuring everyone stays aligned and empowered to provide exceptional customer service. Expect an energetic environment where your contributions matter, and every day brings new challenges and opportunities to excel!<h3 class="jobSectionHeader">
DOES THIS SOUND LIKE YOU?</h3>
To thrive as an Auto Bodily Injury Claims Specialist at Lonestar, you will need a blend of technical knowledge and superior interpersonal skills. With 3-5 years of experience in Auto Bodily Injury/Casualty claims, you should possess a Texas Licensed Adjuster certification and familiarity with multi-state licensing is a plus. Proficiency in legal and medical terminology will aid in conducting thorough investigations and preparing accurate claim evaluations. Strong negotiation and analytical skills are essential for effectively resolving claims and presenting them for settlement authority. You should be comfortable in an automated claims processing environment, utilizing various software tools to document policy status, coverage, liability, and damages accurately.
A knack for organization and the ability to maintain positive relationships with customers, co-workers, and third parties will be key to your success. You will also benefit from knowledge of fraud reduction practices and state-specific regulations, ensuring a compliance-driven approach to your role.
Knowledge and skills required for the position are:<ul><li>
Review &amp; determine course of action on each file assigned</li><li>
utilizing technical knowledge &amp; experience for the purpose of supporting final disposition of a loss.</li><li>
Conduct thorough investigations and keep accurate and relevant documentation of file activity on each claim assigned including coverage</li><li>
liability status</li><li>
and damages that are applicable for each claim.</li><li>
Process Bodily Injury</li><li>
and coverage claims in accordance with established office procedures.</li><li>
Work closely with Third Parties</li><li>
plaintiff counsel and Claims Director to determine necessary injury and coverage investigation.</li><li>
Research case and statutory law in order to conduct proper claim investigation.</li><li>
Document policy status</li><li>
coverage</li><li>
liability and damages on all claims and notify re-insurer on qualifying claims.</li><li>
Prepare and present claim evaluations for the appropriate settlement authority.</li><li>
Maintain reasonable expense factors.</li><li>
Handle other duties as assigned.</li></ul>
QUALIFICATIONS REQUIRED:<ul><li>
Minimum of 3-5 years in Auto Bodily Injury/Casualty claims experience a MUST!</li><li>
Texas Licensed Adjuster - All Lines is required (Multi-State licensing is preferred)</li><li>
Non-Standard insurance experience a plus, not required</li><li>
Bi-lingual a preferred but not required!</li><li>
Knowledge of legal and medical terminology.</li><li>
Excellent negotiation, analytical, organizational, and interpersonal and communication (verbal, written, and phone) skills.</li><li>
Strong skills in the areas of verbal and written communication with an ability to develop and maintain positive customer experience, co-worker, management and third-party relationships.</li><li>
Experience in an automated claims processing work environment</li><li>
Knowledge of fraud reduction practices</li><li>
General working knowledge of policies</li><li>
file procedures</li><li>
state rules and regulations.</li><li>
Ability to pass written examinations where required by state statutes to become a licensed Claims Adjuster.</li></ul><h3 class="jobSectionHeader">
MAKE YOUR MOVE</h3>
If this sounds like the right job for you, don't wait - apply today to join our team. We look forward to hearing from you!</div>

Auto Bodily Injury Claims Specialist

North East Medical Services

<div>SUMMARY OF POSITION: 
The Patient Account Specialist I interprets EOBs for correct payment verification, adjustments, and denials. The Patient Account Specialist I is also responsible for handling outstanding claims on aging reports and resolving patient inquiries regarding billing statements and insurance overage-related matters. The Patient Account Specialist I has to maintain up-to-date knowledge about CPT, ICD-10 CM, billing regulations, and payers' requirements. The Patient Account Specialist I has to comply with HIPAA guidelines and maintain confidentiality regarding patient account status and the organization's financial affairs.
<h1 class="jobSectionHeader">ESSENTIAL JOB FUNCTIONS:</h1><ul><li>
Reviews, edits, processes, and submits electronic and hardcopy claims to various payers (Medicare, Medicaid, Managed Care, and Private Insurance) for FQHC (Federally Qualified Health Centers) and FFS (Fee-For-Service) reimbursement, ensuring accuracy of payment entries and completeness of charge capture information.</li><li>
Maintains up-to-date knowledge of medical billing requirements for FQHC Medi-Cal, Medicare, state, local programs, and private insurance payers.</li><li>
Reports issues or payment trends (e.g., charges applied to the wrong visit, incorrect billing codes) to the supervisor for resolution.</li><li>
Edits charge/claim details and corrects submission errors to ensure accuracy.</li><li>
Researches and resolves outstanding claims on aging reports to minimize delays in reimbursement.</li><li>
Responds to payer requests and remittance advices promptly and professionally, including phone calls, letter responses, appeals, and submission of medical records or additional information as required.</li><li>
Under the guidance of the Patient Account Specialist II, addresses patient inquiries and billing complaints by making necessary adjustments, exploring all options to secure claim payments, referring complex issues to appropriate staff, and ensuring proper follow-up.</li><li>
Posts charges and submits claims for NEMS physicians&rsquo; hospital visits.</li><li>
Provides training and support to the Billing Department and front desk staff in Member Services, Medical, Dental, Optometry, Laboratory, and Radiology Departments.</li><li>
Adheres to policies and procedures for billing records retention.</li><li>
Acts as a liaison between physicians, insurance companies, and third-party organizations by processing and verifying invoices, ensuring claim reimbursements, and auditing patient accounts.</li><li>
Performs additional duties as assigned by management.</li></ul><h1 class="jobSectionHeader">
</h1><ul><li>Completion of an AA/AS degree is required, and a 4-year university diploma is preferred or maybe substituted with a minimum of 3 years of work experience in healthcare.
</li><li>Working experience in a healthcare or FQHC setting is preferred</li><li>
Working experience with Epic PB Resolute is preferred</li><li>
Familiar with Medicare, Medicaid, Private insurances, Managed Care (HMO &amp; PPO), CPT, and ICD-10 CM</li><li>
Must have excellent analytical and communication skills</li><li>
Must be proficient in computer skills</li><li>
Ability to write business correspondence</li><li>
Strong organizational skills to coordinate multiple, varied billing processes simultaneously</li><li>
Upholds high customer service standards in a demanding and complex health care organization</li><li>
Demonstrates initiative, resourcefulness, integrity and dedication to timeliness to achieve high customer satisfaction levels</li>
Self-motivated, diligent, organized, resourceful, responsible, and enthusiastic 
<li>
</li></ul>LANGUAGE:<ul><li>
Proficient in written and spoken English and Chinese (Cantonese and/or Mandarin)</li>
Fluent in other languages is an asset 
<li>
</li></ul>STATUS:<ul><li>
This is an FLSA Non-exempt position.
</li><li>This is not an OSHA high-risk position.</li>
This is a Full Time position. 
<li>
</li></ul>NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).</div>

PATIENT ACCOUNT SPECIALIST I

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