Claims Specialist III

CareSource•Dayton, OH

3d•Onsite

About The Position

The Claims Specialist III is responsible for capturing, resolving/facilitating resolution, and reporting on claim adjustment requests. This role involves resolving complex Coordination of Benefits (COB) issues, processing and adjusting a wide variety of claims accurately and timely, and acting as a technical resource for training and coaching. The Claims Specialist III will also assist providers with inquiries, identify and trend claims payment errors, and ensure compliance with regulatory requirements.

Requirements

High School Diploma or equivalent is required
Minimum of one (1) year of experience in claims environment or related healthcare operations experience required
Proficient in Microsoft Office Suite, to include Word, Excel and PowerPoint
Medical terminology; CPT and ICD coding knowledge strongly preferred
Knowledge of medical billing practices
Intermediate level data entry skills
Excellent written and verbal communication skills
Ability to develop, prioritize and accomplish goals
Effective listening and critical thinking skills
Strong interpersonal skills and a high level of professionalism
Ability to coach and provide feedback effectively
Effective problem solving skills with attention to detail
Ability to work independently and within a team environment

Nice To Haves

Previous experience in an HMO or related industry preferred
Previous Medicare/Medicaid dual eligible claims experience is preferred
Managed Care Organization or related healthcare industry experience preferred

Responsibilities

Resolve complex COB issues through member information updates and adjustment of claims
Maintain accountability for daily tasks and goals to ensure completion of requests within requested SLA and department standards
Identify potential process improvements
Work with peers to ensure implementation of identified process improvements through the Plan, Do, Study, Act (PDSA) cycle with proper documentation updates and sharing of improvement with team and department
Process/adjust a wide variety of claims accurately and timely following established guidelines for accuracy, quality and productivity
Act as a technical resource for training, providing job shadowing, departmental communication, and coaching
Ensure all assigned provider issues are resolved and communicated to the provider within appropriate timeframes and claims resolutions are coordinated with all appropriate departments in order to resolve
Assist providers with inquiries including but not limited to; verifying proper medical coding, explanation of benefits, negative balance requests, claims, and appeal procedures
Identify, track and trend claims payment errors in order to determine root causes and actions needed to correct problems.
Work directly with Configuration, Network Operations, and Service Center through resolution of payment errors.
Ensure reporting on provider inquires and complaints is compliant with current and future regulatory and accreditation bodies such as; ODJFS, MDCH, CMS, OFIR, NCQA and URAC
Adhere to all HIPAA, State, and Federal requirements and regulations at all times in existing and future lines of business
Perform any other job related instructions, as requested