Claims Operations Specialist

SmithRx • Lehi, UT

5d

About The Position

As a Claims Specialist, you will play a pivotal role in ensuring exceptional member satisfaction and operational efficiency within our dynamic Health-Tech environment. You will be responsible for the accurate and timely processing of complex non-electronically submitted claims, including direct member reimbursements and commercial out-of-network claims. Beyond routine processing, this role demands proactive problem-solving, acting as a critical liaison between members and our clinical team for denied reimbursements, and initiating prior authorization processes to ensure seamless continuity of care. You will leverage your expertise to uphold claims integrity, drive process improvements, and provide essential cross-functional support to our account management, member support, and other customer success teams, contributing directly to our mission of transforming healthcare.Projects and other tasks that may arise and be assigned as needed.

Requirements

• 2+ year of experience in a healthcare claims role, preferably in a pharmacy setting or licensed as a pharmacy technician.
• Prior working knowledge of medical or pharmacy claims processing.
• Excellent organization skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
• Microsoft Excel skills required.
• Impeccable attention to detail and accuracy in work.
• Strong problem solving, written and verbal communication, and interpersonal skills
• Ability to work independently as well as part of an extended, cross-functional team
• Self-driven, results-oriented work ethic with a positive outlook
• Ability to take initiative with little to no direction

Responsibilities

• Responsible for ensuring timely completion of non-electronically processed claims such as direct member reimbursement claims and commercial out-of-network claims.
• Ensure claims approvals and/or denials are made in accordance with company practices and procedures. Timely execution on member communications at scale, including mail-outs through our third-party mail vendor.
• Maintain reimbursement queue to meet the department's SLA’s. Completion of assigned claim cases in accordance with daily expectations.
• Sustain integrity of all existing claims processes by ensuring all process documentation is up to date.
• Participate in process improvement and quality assurance opportunities.
• Collaborate and provide cross-functional support to account management, member support, and other customer success teams.
• Act as a liaison between the clinical team and the member for denied reimbursements, initiating the prior authorization (PA) process to ensure proactive member support.
• Participate in internal meetings to help support initiatives and projects.
• Ability to prioritize and complete high-volume cases/claims.

Benefits

• Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life and AD&D Insurance
• 3 Weeks Paid Time Off
• Paid Company Holidays
• Paid Parental Leave Benefits
• Flexible Spending Benefits
• 401(k) Retirement Savings Program
• Short-Term and Long-Term Disability
• Wellness Benefits
• Commuter Benefits
• Employee Assistance Program (EAP)
• Well-stocked Kitchen In Office Locations
• Professional Development and Training Opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed