Senior Medical Claims Specialist

Location: In-Office Glastonbury, Connecticut

Job Title: Sr. Medical Claims Specialist

Schedule: 11:30am-8pm, Monday-Friday (not a remote position)

Join our growing company and be part of a team with great accomplishment. We are hiring an experienced Sr. Medical Claims Specialist with at least 4 years of prior experience that has the ability to work in a fast-paced environment. Great interpersonal and communication skills are a must with strong attention to detail and the ability to multi-task and prioritize.

The position will perform administrative tasks related to client health premiums and medical out of pocket expenses. Daily interaction with clients to provide information in response to inquiries about products and services, and handle and resolve complaints by performing the following duties.

Duties and Responsibilities include the following.

Leads the claims/customer service team.
Provides customer service and will processes medical claims for specific programs.
Processes or adjust medical insurance claims in accordance with policies and procedures. *
Answers phones and respond to client inquiries related to payments made on their behalf to medical providers.*
Answers phones and responds to medical provider inquiries related to payments made or due to behalf of program clients.*
Makes outgoing calls to medical providers and insurance companies, or the like.*
Responsible for having the ability to read explanation of benefits, claim forms and healthcare terminology.*
Identifies, researches, resolves claim issues, and requests for additional documentation.*
Promotes teamwork and service delivery success.*
Ensures contractual performance guarantees related to payment processing timeliness and accuracy are met.*
Ensures contractual performance guarantees related to various means of client communications are met such as phone, email, and mail.*
Processes medical payments for clients.*
Assists in the client appeals process as backup.*
Creates and updates financial batch records as the backup for processing by accounting.*
Manages workflow for the program to ensure service levels are achieved.*
Approves letter queue as backup when needed for outgoing mail.
Updates policy and procedures for department.
Works with client’s that have high medical utilization.*
Recommends process improvements.*
Recognizes, documents and alerts the manager of escalated issues.
Reviewing and denying pending W9 claims.
Point person on staff for questions.
Performs other duties as assigned.

Qualifications:

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 functions.

Computer Skills:

To perform this job successfully, an individual should have knowledge of word processing software, spreadsheet software, internet software, time keeping system, proprietary software, and medical coding/billing or insurance claims processing strongly preferred.

Education/Experience:

Associate's degree (A. A. / A. S.) or equivalent from two-year college or technical school; or four or more years related experience and/or training; or equivalent combination of education and experience.

Specialized Training:

Knowledge of medical insurance practices including enrollment, payment terms related to insurance premiums and out of pocket expenses, benefits coordination with other insurance coverage, and ensuring payer of last resort. Prior lead experience preferred.

Certificates and Licenses:

Medical coding/billing strongly preferred.

Knowledge, Skills, and Other Abilities:

Speaking which includes talking to others to convey information effectively
Professionalism
Knowledge of medical insurance practices including enrollment, payment terms related to insurance premiums and out of pocket expenses, benefits coordination with other insurance coverage, and ensuring payer of last resort
Analytic Skills which include the ability to review and understand payment and account history
Active Listening which includes giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times
Service Orientation which includes actively looking for ways to help people
Writing which includes communicating effectively in writing as appropriate for the needs of the audience
Reading Comprehension which includes an understanding written sentences and paragraphs in work related documents
Proficiency with all MS Office applications including Microsoft Excel, Microsoft Word, and Microsoft Outlook
Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on timely analyses
Precise attention to detail

The above is intended to provide general guidance regarding the responsibilities of the position. It is not intended to be an all-encompassing definition of what the position entails and may be changed at the discretion of Senior Management at any time.

PAI is an equal employment and affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, religion, age, national origin, disability, veteran status, sexual orientation, gender identity or expression, marital status, ancestry or citizenship status, genetic information, pregnancy status or any other characteristic protected by law.

Job Type: Full-time

Pay: From $26.00 per hour

Benefits: