Claims Specialist II
About The Position
The Claims Specialist II performs data analysis, audits, and finalizes adjudication results for claims designated for pre-payment review, and conducts post-payment reviews of claim adjudication results. The role researches and applies billing guidelines and policies established by CMS, NC Medicaid, and Trillium. It also assists providers by phone or email with claims-processing questions and communicates with internal and external stakeholders to facilitate efficient claims resolution. The position is remote within North Carolina. The employee must reside in North Carolina and be able to travel within the catchment area as required.
Requirements
- High school diploma or GED and two years of experience in claims processing, billing, or medical coding, or an equivalent combination of education and experience.
- Valid driver's license.
- Must reside within North Carolina.
- Must be able to travel within the catchment area as required.
- Must be legally authorized to work in the United States without requiring employment sponsorship now or in the future.
Nice To Haves
- Associate's degree in Healthcare Administration, Business, or a Human Services field such as Psychology or Social Work.
- Hospital claims experience and knowledge.
- Experience in physical health claims processing or medical coding.
- Experience working with managed care billing software.
- Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS), or similar certification.
Responsibilities
- Analyze and audit claims adjudication results to determine whether claims were accurately submitted and processed according to NC Medicaid guidelines.
- Analyze and audit claim attachments and medical documentation needed to adjudicate claims appropriately.
- Analyze and audit claims delayed in adjudication because of rejection errors, and take appropriate action.
- Identify adjudication errors, provider billing errors, and needs for technical assistance.
- Review and apply departmental training, published coverage policies, and other NCDHHS documents to ensure claims systems and manual processes incorporate required actions.
- Provide training, education, and technical assistance to provider agencies based on analysis or audit findings, including basic claim submission guidelines, denial management, and system use and updates.
- Recognize and report suspected system issues or concerns to the immediate supervisor for follow-up based on data analysis.
- Assist providers by phone or email with claims-processing questions and communicate with internal and external stakeholders to facilitate claims resolution.
Benefits
- Collaborative, mission-driven work environment.
- Competitive benefits and work-from-home options for most positions.
- Opportunities for professional growth in a diverse, inclusive culture.
- Health insurance with no premium for employee coverage.
- Flexible Spending Accounts.
- 24 days of paid time off plus 12 paid holidays in the first year.
- NC Local Government Retirement Pension (defined-benefit plan).
- 401(k) with 5% employer match and immediate vesting.
- Public Service Loan Forgiveness qualifying employer.
- Quarterly stipend for remote work supplies.
- Flexible work schedules for some roles with management approval.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
