medical claims specialist

The Woman's Health Pavilion

<p>The Woman's Health Pavilion is a growing OB/GYN practice, established in 1971.<br/>We are seeking a detail-oriented and knowledgeable Medical Claims Specialist to join our healthcare team. The ideal candidate will be responsible for managing and processing medical claims efficiently, ensuring accurate coding, billing, and reimbursement. This role is vital in maintaining the financial health of our healthcare operations and providing excellent service to our patients and providers. Prior experience with medical billing, coding, and electronic health record systems is highly valued. The position offers an opportunity to work in a professional environment dedicated to accuracy, compliance, and patient care excellence.</p><p><b>Duties</b></p><ul><li>Review and process medical claims using EMR and EHR systems to ensure timely submission and reimbursement</li><li>Apply appropriate medical coding including ICD-10 and ICD coding standards for accurate claim generation</li><li>Verify insurance coverage and patient eligibility prior to claim submission</li><li>Resolve claim denials or rejections by analyzing errors related to medical records or coding inaccuracies</li><li>Collaborate with healthcare providers to clarify documentation discrepancies</li><li>Maintain detailed records of claims processed and follow up on outstanding payments or collections</li><li>Ensure compliance with healthcare regulations and insurance policies during all claim handling activities</li><li>Assist in updating and maintaining accurate medical records related to billing and claims processing</li></ul><p><b>Skills</b></p><ul><li>Proficiency in medical billing, coding (ICD-10), and medical records management</li><li>Strong understanding of medical terminology and healthcare documentation standards</li><li>Experience working with EMR/EHR systems for claims processing and record management</li><li>Knowledge of insurance policies, medical collections, and reimbursement procedures</li><li>Ability to interpret complex medical data and accurately assign appropriate codes</li><li>Excellent organizational skills with attention to detail to minimize errors in claims processing</li><li>Effective communication skills for collaborating with healthcare providers, insurance companies, and patients</li><li>Prior experience in a medical office setting is preferred but not required; training will be provided as needed</li></ul><p>Qualifications</p><ul><li>High School Diploma/GED</li><li>Experience a plus but not required</li><li>Good verbal and written communication skills.</li><li>Basic understanding of medical ICD 9/ 10 codes and CPT medical billing codes.</li><li>Good telephone and patient relation skills.</li><li>Detail oriented and ability to prioritize work.</li><li>OB/GYN experience a plus</li></ul><p>This position offers a rewarding opportunity for professionals passionate about healthcare administration, coding accuracy, and efficient claims management.</p><p>** This position is in-office only and does not offer remote work. **</p><p>Pay: $20.00 - $25.00 per hour</p><p>Benefits:</p><ul><li>401(k)</li><li>Dental insurance</li><li>Flexible schedule</li><li>Flexible spending account</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul><p>Work Location: In person</p>

Medical Claims Specialist

Onco360

<div><div>We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in <b>Buffalo, NY. </b>This will be a Full-Time position.<b> This position must be located within driving distance to our pharmacy, with a hybrid work style.</b></div>
<div></div><div>Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.</div>
<div></div><div><b>Starting salary from $23.00 an hour and up</b></div><br>
<div></div>
<div></div><div>We offer a variety of benefits including:</div>
<ul><li>Medical; Dental; Vision</li>
<li>401k with a match</li>
<li>Paid Time Off and Paid Holidays</li>
<li>Tuition Reimbursement</li>
<li>Company paid benefits &ndash; life; and short and long-term disability</li>
</ul><div><b>Pharmacy Adjudication </b><b>Specialist Major Responsibilities:</b></div>
<div>The Pharmacy Adjudication Specialist will adjudicate pharmacy claims, review claim responses for accuracy. ensure prescription claims are adjudicated correctly according to the coordination of benefits, resolve any third-party rejections, obtain overrides if appropriate, and be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections</div>
<div></div><div>Pharmacy Adjudication Specialists at Onco360...</div>
<ul><li>Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.</li>
<li>Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information..</li>
<li>Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.</li>
<li>Adjudicates pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and reviews claim responses for accuracy before accepting the claim.</li>
<li>Contacts insurance companies to resolve third-party rejections and ensures pharmacy claim rejections are resolved to allow for timely shipping of medications. Performs outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays</li>
<li>Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)</li>
<li>Manages all funding related adjudications and works as a liaison to Onco360 Advocate team.</li>
<li>Assists pharmacy team with all management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment.</li>
<li>Serves as customer service liaison to patients regarding financial responsibility prior to shipments, contacts patients to communicate any copay discrepancy between quoted amount and claim and collects payment if applicable.</li>
<li>Document and submit requests for Patient Refunds when appropriate.</li>
</ul><div>Pharmacy Adjudication Specialist Qualifications and Responsibilities...</div>
<div><ul><li>Education/Learning Experience
<ul><li>Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication</li>
<li>Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Work Experience
<ul><li>Required: 1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
<li>Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
</ul></li></ul><ul><li>Skills/Knowledge
<ul><li>Required: Pharmacy/NDC medication billing, Pharmacy claims resolution, PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, NCPDP claim rejection resolution, coordination of benefits, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills</li>
<li>Desired: Knowledge of Foundation Funding, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Licenses/Certifications
<ul><li>Required: Registration with Board of Pharmacy as required by state law</li>
<li>Desired: Certified Pharmacy Technician (PTCB)</li>
</ul></li></ul><ul><li>Behavior Competencies
<ul><li>Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skills</li></ul></li></ul></div></div>

Pharmacy Claims Adjudication Specialist

CodeMax Medical Billing

<div><p><b>Reports to: Claims Supervisor</b></p><p><b>
Employment Status: Full-Time</b></p><p><b>
FLSA Status: Non-Exempt</b></p><p><b>
Work Location: On-site - Fort Lauderdale, FL</b></p><p>
</p><p><b><i>Job Summary:</i></b></p><p>
To ensure a timely and accurate collection of medical claims. The Claims Specialist will work closely with insurance companies to rectify payment denials, settle disputes, and receive due reimbursements. The ideal candidate will possess strong communication skills, a deep understanding of medical billing and coding, and the determination to resolve outstanding claims.</p><p><b><i>
Duties/Responsibilities:</i></b></p><ul><li>
Reviews and work on unpaid claims, identifying and rectifying billing issues.</li><li>
Communicate with insurance companies regarding any discrepancy in payments if necessary.</li><li>
Conducts research and appeals denied claims timely.</li><li>
Reviews Explanation of Benefits (EOBs) to determine denials or partial payment reasons.</li><li>
Provides detailed notes on actions taken and the next steps for unpaid claims.</li><li>
Collaborate with the billing team to ensure accurate claim submission.</li><li>
Maintains a comprehensive understanding of the insurance follow-up process, payer guidelines, and compliance requirements.</li><li>
Resubmits claims with necessary corrections or supporting documentation when needed.</li><li>
Tracks and documents trends related to denials and work towards a resolution with the billing team.</li><li>
Assist patients with inquiries related to their insurance claims, providing clear and accurate information.</li><li>
All other duties assigned by the department supervisor and/or management team.</li></ul><p><b><i>
Required Skills/Abilities:</i></b></p><ul><li>
Proficiency in healthcare billing software.</li><li>
Strong analytical, organizational, and multitasking skills.</li><li>
Excellent verbal and written communication abilities.</li><li>
Ability to navigate payer websites and use online resources to resolve outstanding claims.</li></ul><p><b><i>
Education and Experience:</i></b></p><ul><li>
High school diploma or equivalent required.</li><li>
Prior experience in medical billing collections or a similar role.</li><li>
Knowledge of medical terminology, CPT and ICD-10 coding is a plus.</li><li>
Knowledge of HIPAA and other healthcare industry regulations.</li></ul><p>
Benefits</p><ul><li>
Health Insurance</li><li>
Vision Insurance</li><li>
Dental Insurance</li><li>
401(k) plan with matching contributions</li></ul><p>
</p><p>CodeMax is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.</p><p>
CodeMax is a participating employer in the federal E-Verify program.</p></div>

Claims Follow-Up Specialist

Gallagher

<div><b>Introduction</b><br>
<div>
At Gallagher Bassett, we're there when it matters most because helping people through challenging moments is more than just our job, it&rsquo;s our purpose. Every day, we help clients navigate complexity, support recovery, and deliver outcomes that make a real difference in people&rsquo;s lives. It takes empathy, precision, and a strong sense of partnership&mdash;and that&rsquo;s exactly what you&rsquo;ll find here. We&rsquo;re a team of fast-paced fixers, empathetic experts, and outcomes drivers &mdash; people who care deeply about doing the right thing and doing it well. Whether you're managing claims, supporting clients, or improving processes, you&rsquo;ll play a vital role in helping businesses and individuals move forward with confidence. Here, you&rsquo;ll be supported by a culture that values teamwork, encourages curiosity, and celebrates the impact of your work. Because when you&rsquo;re here, you&rsquo;re part of something bigger. You&rsquo;re part of a team that shows up, stands together, and leads with purpose.
</div><br>
<b>Overview</b><br>
<div><b>
Salary:</b> Salary can be up to $120,000 per year, dependent upon experience</div><div><b>
Claims Background:</b> Professional Liability Claims, Paralegal experience, or related insurance support role<br>
<b>Jurisdictional Experience:</b> Open to any<br>
<b>Active Adjuster Licenses:</b> Must be willing to obtain all licenses as required by the manager within a specified timeframe</div><div>
</div><div>
The Claims Specialist within GB Specialty is responsible for managing moderately complex <b>Healthcare Professional Liability</b> claims. This role manages the full claim life cycle, including coverage analysis, investigation, evaluation, and resolution, while ensuring claims are handled in accordance with client expectations, policy obligations, and regulatory requirements.</div>
<br>
<b>How you'll make an impact</b><br>
<ul><li>
Analyzes coverage and settles moderately complex claims in Healthcare Professional Liability.</li><li>
Generally, incumbent does not work on workers&rsquo; compensation claims.</li><li>
Able to manage the full-life cycle of all assigned claims files.</li><li>
Analyzes coverage and determines defense obligations.</li><li>
Under minimal supervision, conducts thorough analysis and investigations necessary to determine claims exposure and recommend appropriate settlement strategies and action plans.</li><li>
Creates reservation of rights and coverage denial letters.</li><li>
Negotiates settlements with clients, client attorneys, and Public Adjusters.</li><li>
Interacts extensively with various parties involved in the claims process, and may recommend retaining the advice of outside experts as necessary.</li><li>
Prepares reserve and settlement authority requests for client and carrier approval.</li><li>
May act as a client advocate with carriers to ensure proper claims handling, including any necessary scoping, estimating, and addressing of coverage.</li><li>
Has a solid understanding of claims processing and the insurance brokerage business.</li><li>
Has a basic understanding of the terminology and case law associated with correctional medicine professional liability claims.</li><li>
Handles claims consistent with clients&rsquo; and corporate policies, procedures and best practices and in accordance with statutory, regulatory, and ethical requirements.</li><li>
Incumbents at this level should be able to work at full caseload capacity.</li></ul>
<br>
<b>About You</b><br>
<div><b>
Claims Background:</b> Paralegal experience, junior professional liability claims experience, or insurance claims support background, preferably within healthcare or medical professional liability</div><div><b>
Jurisdictional Experience:</b> Open to any<br>
<b>Active Adjusters&rsquo; Licenses:</b> Not required initially; must be willing to obtain licenses as directed</div><div></div><div><b><br>
Required:</b></div><br>
<div></div><ul><li>
Bachelor's Degree Required</li><li>
Minimum 2 years of experience in claims, insurance, paralegal, legal support, or a related environment.</li><li>
Strong insurance fundamentals and understanding of claims processes.</li><li>
Ability to analyze documentation, summarize facts, and support coverage and liability determinations.</li><li>
Computer proficiency with claims systems and standard business software.</li><li>
Must be able to obtain required adjuster licenses within designated timeframes.</li></ul><div><b><br>
Preferred:</b></div><ul><li>
Prior experience within healthcare (medical malpractice) claims is a plus</li></ul><div><b>
Behaviors:</b><ul><li>
Ability to think critically, solve problems, plan and organize activities, serve clients, negotiate, and communicate effectively in writing and verbally.</li><li>
Strong analytical skills to support claims decisions and issue resolution.</li><li>
Ability to interpret policies, records, and related documentation.</li></ul><div>
#LI-TJ1</div><div>
#GBSpecialtyCareers</div></div></div><div></div>

Claim Specialist - Healthcare Professional Liability

Eplanet Global

<p><b>Job Title: AR Specialist &ndash; Medical Billing</b></p><p><b>Location:</b> Karachi (Onsite)<br/><b>Experience:</b> 2&ndash;5 Years (US Healthcare AR)<br/><b>Shift:</b> US Shift (Night)<br/><b>Salary Range:</b> 150K&ndash; 160K PKR (depending on experience)</p><p><b>Job Summary:</b></p><p>I am looking for a skilled <b>AR Specialist (Medical Billing)</b> with hands-on experience in US healthcare revenue cycle management. The candidate will be responsible for managing insurance follow-ups, claim resolutions, and ensuring maximum reimbursement by working on denied, rejected, and unpaid claims.</p><p><b>Key Responsibilities:</b></p><ul><li>Work on <b>Accounts Receivable (AR)</b> for US healthcare clients</li><li>Perform <b>insurance follow-ups</b> on unpaid/underpaid claims (via calls/portals)</li><li>Analyze and resolve <b>denied and rejected claims</b></li><li>Handle <b>payment posting discrepancies</b> and reconciliation</li><li>Ensure timely <b>appeals filing</b> for denied claims</li><li>Work on <b>aging reports</b> (30/60/90/120+ days) and prioritize collections</li><li>Coordinate with billing and coding teams to fix claim issues</li><li>Maintain accurate documentation of follow-ups and actions taken</li><li>Meet daily/weekly productivity and collection targets</li></ul><p><b>Required Skills &amp; Qualifications:</b></p><ul><li>Bachelor&rsquo;s degree (preferred)</li><li>2&ndash;5 years of <b>US Medical Billing AR experience</b></li><li>Strong understanding of <b>RCM (Revenue Cycle Management)</b></li><li>Knowledge of <b>CPT, ICD-10, HCPCS codes</b></li><li>Familiarity with <b>insurance portals</b> (e.g., Availity, Navinet)</li><li>Experience with <b>denial management &amp; appeals</b></li><li>Good communication skills for <b>US insurance calling</b></li><li>Proficiency in MS Excel and billing software</li></ul><p><b>Preferred:</b></p><ul><li>Experience in <b>specialties</b> (e.g., Radiology, DME, Internal Medicine, etc.)</li><li>Exposure to <b>EHR/EMR systems</b> (e.g., Kareo, AdvancedMD, eClinicalWorks)</li></ul><p><b>KPIs / Performance Metrics:</b></p><ul><li>AR aging reduction</li><li>Collection ratio / recovery rate</li><li>Denial resolution turnaround time</li><li>Productivity (claims handled per day)</li><li>Quality &amp; accuracy of follow-ups</li></ul><p>Job Type: Full-time</p><p>Pay: Rs150,000.00 - Rs160,000.00 per month</p><p>Work Location: In person</p>

AR Specialist – Medical Billing

Medical Foot Care Center

<p>Established physician office seeking an experienced Medical Claims Follow-Up Specialist to manage insurance accounts receivable, denials, and appeals. This role is ideal for someone who enjoys problem-solving, working accounts, and ensuring accurate reimbursement from commercial and government payers.</p><p>Small, team-oriented office with a supportive work environment and long-term stability.</p><p>Key Responsibilities</p><ul><li>Review and follow up on <b>insurance denials and unpaid claims</b></li><li>Submit <b>corrected claims and appeals</b> as needed</li><li>Work with payers including UnitedHealthcare, Aetna, Cigna, and Blue Cross Blue Shield</li><li>Analyze EOBs and ensure <b>accurate payment posting and adjustments</b></li><li>Identify trends in denials and recommend solutions</li><li>Correct errors related to <b>demographics, coding, and charge entry</b></li><li>Communicate with insurance companies regarding claim status</li><li>Assist front office with patient account questions as needed</li></ul><p>Qualifications</p><ul><li>Minimum <b>1&ndash;2 years experience in medical claims follow-up / AR</b></li><li>Strong understanding of <b>insurance guidelines and billing processes</b></li><li>Experience with <b>denials, appeals, and payment posting</b></li><li>Familiarity with CMS and commercial payer rules</li><li>Strong analytical and organizational skills</li><li>Ability to manage multiple accounts in a fast-paced environment</li></ul><p>Additional Requirements</p><ul><li>Proficient in Microsoft Word, Excel, and practice management systems</li><li>High school diploma or equivalent required</li><li>Ability to sit/stand and work at a computer for extended periods</li></ul><p>Compensation &amp; Schedule</p><ul><li>Full-time, Monday&ndash;Friday (9 AM &ndash; 5 PM)</li><li>Compensation: <b>Based on experience</b></li></ul><p>Additional Information</p><ul><li>This is an <b>in-office position</b></li><li>Benefits: Not offered at this time</li></ul><p>Job Type: Full-time</p><p>Experience:</p><ul><li>Insurance specialist: 1 year (Required)</li><li>Claim Follow Up: 1 year (Required)</li></ul><p>Work Location: In person</p><p>Pay: $18.00 - $23.00 per hour</p><p>Benefits:</p><ul><li>Paid time off</li></ul><p>Work Location: In person</p>

Medical Claims Follow up Specialist

The Plastic Surgery Center

<p>The Advanced Reconstructive Surgery Alliance (ARSA) and its affiliates are the largest Reconstructive Plastic Surgery medical practice in the country. Our expanding team of top tier physicians, coupled with our continued medical advancements, allows us to offer patients extraordinary clinical services with 5-star experience. We have a bold vision with a desire to revolutionize the industry; meeting patient needs while favorably transforming their lives. Common across the enterprise is not only the commitment to providing superior patient care, but to employee satisfaction and growth opportunities. It is a culture of teamwork, respect and appreciation for all employees&mdash;whether caring for patients directly or working in a support role.</p><p>We are seeking a <b>Claims Dispute Specialist.</b></p><p>The Claims Dispute Coordinator manages and resolves complex medical claim disputes and appeals with a focus on compliance with the Federal No Surprises Act (NSA) and similar state surprise billing laws. This role requires strong written communication skills, analytical skills and attention to detail. The ideal candidate brings the ability to efficiently prepare strong written arguments based on complex medical claims while effectively managing dispute process deadlines.</p><p><i><b>Key Responsibilities </b></i></p><ul><li>Review and analyze medical claims to ensure accuracy, compliance, and eligibility for appeal or dispute under the NSA or state law</li><li>Investigate claim payments and denials by reviewing clinical documentation, insurance payer contracts, and claim history</li><li>Initiate and manage disputes under the NSA or state law</li><li>Prepare clear and effective written arguments as part of claims dispute processes</li><li>Analyze data and identify insights to support negotiations and dispute arguments</li><li>Collaborate with various teams within ARSA to ensure timely and successful dispute resolution</li></ul><p><i><b>Qualifications and Experience </b></i></p><ul><li>1&ndash;3 years in healthcare claims processing preferred</li><li>Experience with No Surprises Act dispute resolution highly preferred</li><li>Bachelor&rsquo;s degree relevant field preferred</li></ul><p><i><b>Skills </b></i></p><ul><li>Strong analytical and problem-solving abilities</li><li>Strong written and verbal communication skills</li><li>Strong organization skills</li><li>Ability to manage multiple priorities and meet deadlines in a fast-paced environment</li><li>Proficiency in Microsoft Office suite and healthcare practice management systems</li></ul><p><b>Compensation &amp; Benefits:</b></p><ul><li>&middot; Pay Range: $55,000- $60,000annually</li><li><i>the starting rate within this range for this role varies depending on a number of factors, including a candidate&rsquo;s qualifications, skills, competencies, experience, and location.</i></li><li>&middot; Medical, Dental, Vision, Life, HSA and Long-Term Disability insurance</li><li>&middot; 401k and Profit sharing</li><li>&middot; Paid Time Off</li><li>&middot; Contribution to Health Benefits</li><li>Company Discounts on Products &amp; Services</li></ul><p>IND2</p><p>Job Type: Full-time</p><p>Pay: $55,000.00 - $60,000.00 per year</p><p>Experience:</p><ul><li>Medical claims processinfg: 2 years (Required)</li><li>No Surprises Act: 2 years (Required)</li></ul><p>Ability to Commute:</p><ul><li>Red Bank, NJ 07701 (Required)</li></ul><p>Work Location: In person</p>

Claims Dispute Specialist

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