Claims Processing Specialist

Position Summary:

We are seeking a detail-oriented Claims Processing Specialist to support the Claims Processing Team in managing the day-to-day processing of claims received from Third-Party Administrators (TPAs). This role is essential to ensuring the accurate and timely handling of claims, contributing directly to efficient payment operations.

Key responsibilities include processing claim files, generating reports, responding to email inquiries, resolving support tickets, addressing bank return items, and preparing documentation for employer credits. The Claims Processing Specialist plays a critical role in maintaining smooth claims operations and ensuring service standards are met. This position reports to the Claims Processing Supervisor.

Essential Duties and Responsibilities: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Process claims files using multiple internal systems, TPA websites and interact with TPA representatives to ensure claims are processed accurately
• Ensure claim errors are corrected prior to adjudication
• Send various reports to employer groups and TPAs
• Respond to emails from employer groups and TPAs
• Review and solve tickets regarding customer complaints/inquiries, questions, and requests from employer groups, and claim adjustment requests from internal and external clients
• Prepare documents for employer credits
• Support special projects and ad-hoc assignments related to claims and operations efficiency
• Create Ad hoc reports as needed
• Perform other related duties as assigned

Qualifications:

• High attention to detail with strong analytical, organizational, documentation, and time-management skills
• Proven ability to execute established processes and manage daily operational tasks independently
• Maintains good working knowledge of system/internet and online tools used to process claims with the ability to learn and adapt to new systems quickly
• Excellent written and verbal communication skills
• Proven ability to manage multiple priorities effectively in a fast-paced environment
• Demonstrated experience meeting deadlines and performing under pressure on a routine basis
• Clear and professional communication skills with an aptitude for coordinating effectively between multiple teams
• Collaborative mindset with the ability to work effectively across departments and communicate clearly with both internal and external stakeholders

Education/Experience:

• Bachelor’s degree preferred, or equivalent combination of education and relevant experience
• Minimum of three (3) years of experience in medical claims processing
• Customer service experience strongly preferred
• Advanced skills in MS Office (Excel, Word, Outlook, and PowerPoint)
• Strong knowledge of CPT, HCPCS, ICD-10, and claims adjudication processes
• Experience in Medical/Health Insurance experience is preferred
• Experience with claims management software, TPA portals, or other healthcare-related systems a plus.
• Demonstrated track record of meeting accuracy and productivity targets in a high-volume processing environment.

Work Environment: The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

• This is a hybrid position: three days in the office and two days working remotely
• The physical environment primarily involves working at a desk using computer and phone equipment
• Occasional overtime or weekend work may be required for special projects or events
• Able to live our mission, vision, and values

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this office-based job. Reasonable accommodation may be made to enable individuals with disabilities to perform these functions.

• Communicate verbally and professionally
• Answer phones and interact with others
• Walk occasionally around the office to perform job duties
• Sit at a desk for extended periods
• Use keyboard, monitor and telephone
• Maintain close vision and the ability to adjust focus for reading and working on a computer

Disclaimer: The information provided in this job description is intended to outline the general nature and level of work performed by employees within this classification. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required of employees assigned to this position.