Senior Claims Specialist

Pay Plan Title: Data Analyst

Working Title: Senior Claims Specialist

FLSA Status: Exempt

Posting Salary Range: $41,102 - $59,518

Office Location: Remote within North Carolina

POSTING DETAILS:

Make an Impact

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.

Why Work for Us?

Trillium believes that empowering others begins with supporting our team. We offer our employees:

A collaborative, mission-driven work environment
Competitive benefits and work-from-home options for most positions
Opportunities for professional growth in a diverse inclusive culture

Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.

If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!

What We’re Looking For

Trillium Health Resources has a career opening for a Senior Claims Specialist to join our team! The Senior Claims Specialist performs data analysis, auditing and finalizes adjudication results for claims designated for pre-payment review and post payment review of claim adjudication results through research and knowledge of billing guidelines and policies established by CMS, and NC Medicaid as well as Trillium policies and procedures. This position is also responsible for assisting providers by phone or email with claims processing questions as well as communicating with internal and external stakeholders to facilitate efficient claims resolution.

On a typical day, you might:

Analyze and audit claims adjudication results to determine if claims were accurately submitted and processed according to NC Medicaid guidelines.
Analyze and audit claim attachments/medical documentation necessary to appropriately adjudicate a claim.
Analyze, audit and take appropriate actions for claims delayed for adjudication due to rejection errors.
Identify adjudication errors, provider billing errors, and the need for technical assistance.
Ensure the claims system and manual processes are incorporating required actions by reviewing and applying information from departmental trainings, published coverage policies and other NCDHHS documents.
Provide training, education and technical assistance to provider agencies based on analysis or audit findings related to basic claim submission guidelines, denial management, system use and updates.
Recognize and report suspected system issues or concerns to immediate supervisor for follow-up based on data analysis.

Employee Benefits:

Trillium knows that work/life balance is essential. That’s why we offer:

Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval.
Work-from-home options available for most positions
Health Insurance with no premium for employee coverage
Flexible Spending Accounts
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook
401k with 5% employer match and immediate vesting
Public Service Loan Forgiveness (PSLF) qualifying employer
Quarterly stipend for remote work supplies

Qualifications

Required:

High School Diploma/GED and two (2) years of experience in the claims processing or billing or medical coding field; OR
Equivalent combination of education/experience.
Must have a valid driver’s license
Must reside within North Carolina
Must be able to travel within catchment as required.

Preferred:

Associate’s degree in Healthcare Administration, Business, or a Human Services field (such as Psychology, Social Work, etc.)

Hospital claims experience and knowledge
Experience in the areas of physical health claims processing or medical coding
Experience working with Managed Care billing software
Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS) or similar certification preferred.

Deadline for Application: Open Until Filled

How to Apply

To be considered, submit your application and resume through our ADP Career Center. Your resume must include:

Employer name, dates of service (month/year), average hours worked per week, and essential job duties
Education details (degree type, date awarded, institution, field of study)
Licensure/certification information, if applicable

After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You’ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.

Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.

Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.

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