claims processing specialist

Kern Health Systems

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).
 
KHS reasonably expects to pay starting compensation for the position of Claims Operations Senior Specialist, in the range of $35.89 - 45.76 hourly.
 
**Hybrid Position**
 
About us
 
Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.
 
About the role
 
This highly specialized position is responsible for analyzing statistics of all areas of Claims daily; and assisting in priority area as needed. This position is responsible for knowing and performing all functions within the department: Claims Processing, Auditing, Disputes/Rework, Calls, Training, Inventory Control, Systems Testing, Overpayments, and Encounter Processing – and offering suggestions for improvements to Management. This position is also responsible for keeping abreast of Medi-Cal, Commercial and Medicare rules for Dual membership or other LOB (Dental, Vision, LTC, Transplants, Mental Health, Pharmacy, etc.) and training when necessary.
 This position is responsible for identifying area most in need of attention and applying their knowledge and skill to help that specific area to be within operating standards/goals. This position will be required to perform all functions within Claims Operations. This position will use experience to identify areas to improve in workflow, system enhancements, and Auto Adjudication. This position will also be the primary SME for all other Lines of Business from Medicare to Commercial or other new benefits for Medi-Cal.
 
Essential Duties and Responsibilities
 
<ul>
<li>Analyze and identify (on a daily basis) area in Claims Department needing most assistance to hit optimal benchmarks.</li>
<li>Perform Claims Processing at all levels, Auditing, Dispute Processing, Calls, Overpayments, Encounter Processing, Training, Inventory Control and System Testing at optimum levels as needed with flexibility day to day.</li>
<li>Analyze via reports and experience in daily handling of all related department duties and recommend changes to work processes as needed.</li>
<li>Analyze via reports and experience in daily handling of all related department duties and recommend system enhancements/Auto Adjudication as needed.</li>
<li>Write and run reports in Business Objects as needed.</li>
<li>Acts as a resource and provides support to Customer Service and Provider Relations regarding Claims Payments.</li>
<li>Track and trend Provider disputes, denials and calls to effect improvement in compliance with billing rules and/or opportunities for Provider Training.</li>
<li>Key contact and oversight of Supplemental Payment programs via the Claims Department (Prop 56, GEMT, etc.).</li>
<li>Liaison with High Dollar Claim Review Vendor – monitor, verify, and validate data as well as communicate needs to vendor.</li>
<li>Performs other job-related duties as required.</li>
<li>Adheres to all company policies and procedures relative to employment and job responsibilities.</li>
<li>Telecommuting jobs will require some on site meetings/ trainings as identified by management.</li>
</ul>
Employment Standards: 
Bachelor’s degree in business from an accredited university or equivalent required AND ten (10) years of direct experience in combination of a minimum of eight (8) functions: Claims Processing, Auditing, Provider Dispute Processing/Rework, Claim Call Representative, Training, Inventory Control, System Testing, Overpayment Recovery, and/or Encounter Processing. Experience in Medicare, Medi-Cal and Commercial lines of business required.
 <ul>
<li>OR-</li>
</ul>
Fourteen (14) years of direct experience in combination of a minimum of eight (8) functions: Claims Processing, Auditing, Provider Dispute Processing/Rework, Claim Call Representative, Training, Inventory Control, System Testing, Overpayment Recovery, and/or Encounter Processing. Experience in Medicare, Medi-Cal and Commercial lines of business required
 
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

Claims Operations Senior Specialist

Trinity Health

Employment Type: 
Full time
 
Shift: 
Day Shift
 
Description: 
Position located in Westmont, Illinois - remote eligible. Benefit eligible (medical/dental) from the first day of employment.
 
Perform Quality Auditing of Claim Adjudicators and Customer Service Representatives. Audit capitation deductions, preparing summary of findings and disputes to the various HMOs. Review and respond to Stat Fax/Past Due Claim (PDC) inquiries from the HMOs.
 
<ul>
<li>Review claims for accuracy of information into the claims processing system and ensure Standard Operating procedures (SOPs) have been followed. Provide feedback to staff as errors are identified, including where procedures can be found on correct handling when appropriate.</li>
<li>Work closely with Operations Manager to identify areas requiring additional training, either on an individual basis or overall.</li>
<li>Review authorization/claim history to determine handling and appropriateness of deductions. Enter disputed deductions into Excel or Access, depending on the health plan. Review outstanding deductions and follow up with the health plan as needed. Update CHS files upon receipt of health plan’s response to indicate whether or not a credit was received.</li>
<li>Research, document and respond to HMO inquiries within appropriate time frames to avoid future capitation deductions. Responsible for contacting HMO for copies of claims that are not in claims processing system and require entry/adjudication. Responsible for contacting providers when claims have been processed to verify status of accounts.</li>
<li>Enhance department productivity by recommending improvements to the work flow processes and organizational structure. Contribute to team effort by accomplishing related results as determined by management. Attend meetings as necessary either internally or with the HMOs</li>
</ul>
Position Requirements: 
Minimum Education: 
Required: Associate Degree or 5-10 years of claims auditing and/or Managed care experience
 Preferred: Bachelor Degree
 Specify Degree(s): AAPC certification
 Residency: N/A
 
Minimum Experience: 
Required: 3-5 years of previous job-related experience
 Preferred: 6-10 years of previous job-related experience
 Details: Previous job related experience in a managed care environment, claims processing, claims auditing, analysis of claims errors. Familiarity with managed care products. Able to track errors and provide training if needed.
 
Licensure/Certifications: 
Preferred: Certified Professional Coder (AAPC)
 Other: RHIA, RHIT and AAPC
 
Required Skills: 
Ability to plan, coordinate and develop multiple projects
 
Compensation: 
Pay Range: $21.02 - 32.59 per hour
 Actual compensation will fall within the range but may vary based on factors such as experience, qualifications, education, location, licensure, certification requirements, and comparisons to colleagues in similar roles.
 Trinity Health Benefits Summary
 
Our Commitment
 
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

CLAIMS AUDITOR

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

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

FRIENDS OUTSIDE

<div>The CalAIM Medical Billing Specialist is responsible for managing the day-to-day administrative and billing operations related to Enhanced Care Management (ECM) and Community Supports (CS) services. This position supports the organization&rsquo;s CalAIM programming by ensuring accurate claims submission, authorization management, billing compliance, encounter tracking, and reimbursement optimization in accordance with DHCS, Managed Care Plan (MCP), Medi-Cal, and organizational requirements.

The Billing Specialist works closely with care managers, housing support staff, leadership, and Managed Care Plans to ensure timely and compliant billing processes while maintaining accurate records within electronic medical records (EMR/EHR) and billing systems. 
Qualifications:
<ul>
<li>High school diploma or equivalent required; Associate&rsquo;s degree in Medical Billing and Coding, Healthcare Administration, Business Administration, or related field preferred</li>
<li>Minimum of two years of medical billing experience, preferably within Medi-Cal, managed care, behavioral health, or community-based services</li>
<li>Knowledge of CalAIM, Enhanced Care Management (ECM), Community Supports (CS), and Medi-Cal billing practices preferred</li>
<li>Experience with electronic medical record (EMR/EHR) and billing software systems</li>
<li>Understanding of HIPAA regulations, healthcare documentation standards, and claims processing workflows</li>
<li>Strong attention to detail, organizational skills, and ability to manage multiple priorities</li>
<li>Excellent communication and problem-solving abilities</li></ul> 


Key Responsibilities

Billing &amp; Claims Management
<ul>
<li>Submit invoices and claims to Managed Care Plans (MCPs) for ECM and Community Supports services rendered to authorized members</li>
<li>Prepare and submit clean claims electronically or by paper in accordance with payer guidelines, DHCS standards, and MCP requirements</li>
<li>Submit claims utilizing national standard specifications, billing codes, and code sets established by DHCS for ECM and Community Supports services</li>
<li>Ensure maximum reimbursement through accurate billing, coding, and documentation review</li>
<li>Review claims for accuracy, completeness, and compliance prior to submission</li>
<li>Monitor claim status and assigned billing queues daily to support timely payment processing</li>
<li>Manage claims follow-up, denial management, corrections, appeals, and resubmissions as needed</li>
<li>Process and reconcile payer responses, payment postings, and billing reports</li>
</ul>
Authorization &amp; Eligibility Oversight
<ul>
<li>Verify member eligibility with assigned MCPs prior to billing and throughout service enrollment periods</li>
<li>Monitor and maintain ECM and Community Supports authorizations, referrals, and service approvals</li>
<li>Ensure services billed are authorized, medically appropriate, and documented in accordance with DHCS and MCP requirements</li>
<li>Track authorization expiration dates and coordinate reauthorization needs with program staff</li>
</ul>
Documentation &amp; Compliance
<ul>
<li>Maintain accurate and up-to-date data in electronic medical record (EMR/EHR) systems and billing platforms</li>
<li>Ensure documentation supports billed services and complies with ECM and Community Supports standards, including encounter documentation requirements</li>
<li>Maintain strict confidentiality of protected health information in compliance with HIPAA and organizational policies</li>
<li>Support compliance with consent, authorization, and data-sharing requirements related to CalAIM services</li>
<li>Assist with audits, monitoring activities, and reporting requests related to billing and claims processing</li>
</ul>
Coordination &amp; Communication
<ul>
<li>Coordinate with care managers, housing support staff, supervisors, and external partners to obtain necessary documentation and service information</li>
<li>Communicate with MCP representatives regarding claims, authorizations, billing inquiries, and service requirements</li>
<li>Assist staff in resolving documentation deficiencies impacting billing or reimbursement</li>
<li>Participate in interdisciplinary meetings as needed to support program operations and billing integrity</li>
</ul>
Training &amp; Quality Improvement
<ul>
<li>Attend required trainings and maintain current knowledge of CalAIM, ECM, Community Supports, DHCS, and MCP billing requirements</li>
<li>Stay informed on policy, coding, and compliance updates impacting billing practices</li>
<li>Contribute to process improvement efforts to enhance billing accuracy, compliance, and reimbursement outcomes</li></ul></div>

CalAIM Medical Billing Specialist

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

Chatham Orthopaedic Associates

Overview We are seeking a detail-oriented and highly organized Accounts Receivable Specialist to join our finance team. The successful candidate will strive to improve revenue cycle by proactively reviewing accuracy of entered charges, claims data, educating staff and providers, reviewing payers and repressors and ensuring compliance with all federal and state regulations.Essential ResponsibilitiesGenerates aged outstanding insurance report/s and works a minimum of 60 claims in the listing and follows up on unpaid claims as needed.Reviews denials, no pays and other &ldquo;Explanation of Benefits&rdquo;; coordinates problem accounts with providers and charge posters; educates providers and staff on front end issues to improve revenue cycle.Assists awareness of compliance programs as related to coding process.ExperienceMust have at least 2-3 years with claims processing and denials.Athena experience a plusPlease go to our website and complete applicationPay: $18.00 - $27.00 per hourExpected hours: 40.0 per weekBenefits:<ul><li>401(k)</li><li>AD&amp;D insurance</li><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: In person

Accounts Receivable Specialist

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