CLAIMS REVIEW SPECIALIST

State of Arkansas•Little Rock, AR

1d•$39,171 - $57,973•Onsite

About The Position

The Claims Review Specialist plays a critical role in supporting the insurance claims process by reviewing and evaluating claims for accuracy, completeness, and compliance with pre-determined agency policies and regulatory standards. This classification involves verifying claim documentation, investigating discrepancies, and ensuring the timely and efficient resolution of claims.

Requirements

High school diploma or GED.
Two years of experience in clerical or administrative functions.
Strong analytical and problem-solving skills, attention to detail, good written and verbal communication.
Willingness to learn and adapt to new tools, technologies, and processes.
Experience with using standard office software (e.g., Microsoft Excel, Word).
A proactive and team-oriented approach to work.
Familiarity with department related programs.

Nice To Haves

Excellent communication skills both written and verbal
Ability to work well with others in a professional environment
Organization skills to multitask and adapt to changing priorities
Previous Medicare, Medicaid, or Commercial Insurance experience is highly sought.
Familiarity with medical billing and coding is desired.
Experience with MMIS Interchange is preferred.
Background in research or data analysis is considered a plus.

Responsibilities

Assists with various audits, including 3383 retrospective review audit of crossover claims.
Responsible for maintaining and entering information into excel spreadsheets, uploading documentation into Docushare, preparing files for scanning into Docushare, verifying Docushare Scanning.
Handle incoming and outgoing mail, distribute faxes, and perform other duties as assigned to meet changing priorities.
This position is part of the Utilization Review Phone Tree.
Assess insurance claims to ensure all required information is accurate and complete.
Verify claim documentation against policy terms and conditions.
Identify missing or inconsistent information and coordinate with the appropriate personnel to resolve issues.
Document findings and actions taken for each claim in an organized manner.
Communicate claim outcomes and provide necessary explanations to policyholders or internal personnel.
Support fraud detection and prevention efforts by reporting unusual patterns or inconsistencies.
Stay informed on agency policies, industry practices, and relevant regulations.
Collaborate with senior team members and managers to improve claims processing workflows.