Specialist - Technical Health Claims

The Technical Claims Specialist is responsible for supporting the technical management of health insurance claims throughout the submission and adjudication lifecycle. The role ensures compliance with policy provisions, technical guidelines, contractual agreements, system controls, and regulatory requirements while safeguarding the integrity of claims prior to payment. The position focuses on monitoring claims submission quality, enhancing provider compliance, supporting adherence to regulatory standards, analyzing operational performance, and contributing to continuous improvement initiatives that enhance claims processing efficiency and accuracy.

Key Accountabilities

Operations:

▪ Execute technical claims activities and ensure timely processing of health insurance claims in accordance with established procedures.

▪ Ensure compliance with policy provisions, provider agreements, internal policies, regulatory requirements and standards.

▪ Monitor claims transactions and identify invalid, non-compliant, or incomplete claims prior to adjudication and payment.

▪ Support operational activities to ensure service levels and quality standards are achieved.

Data Analysis & Control:

▪ Analyze claims data to identify trends, discrepancies, operational gaps, and improvement opportunities.

▪ Support the implementation and monitoring of controls to ensure compliance with technical claims rules, policy provisions, contractual agreements, and regulatory requirements.

▪ Investigate claims processing exceptions, validation failures, and operational inconsistencies and support resolution activities.

▪ Prepare analytical findings and recommendations to support operational decision-making.

KPI Management and Compliance:

▪ Ensure assigned activities are completed within established KPIs while maintaining compliance with technical and regulatory requirements.

▪ Monitor operational performance indicators and highlight areas requiring corrective actions or improvement.

▪ Support compliance reviews, audits, and regulatory requirements related to claims operations.

QUALIFICATIONS

• Bachelor’s degree in business administration, Healthcare Administration, Insurance, Health Informatics, or a related field.
• Proven experience in health insurance claims operations, technical claims management, or a similar function within an insurance or healthcare environment.
• Strong understanding of the health insurance claims lifecycle, policy interpretation, provider contracts, and technical claims rules.
• Experience in claims submission processes, validation rules, and NPHIES transactions is highly preferred.