Claims Specialist, COE

Relation Insurance•Tulsa, OK

12d•Onsite

About The Position

The Claims Specialist processes and manages claims activities related to the organization’s Healthcare Center of Excellence (COE) programs, ensuring accuracy, timeliness, and compliance with established standards. The individual in this position serves as a key resource for claims investigations, payment discrepancies, billing resolution, and member support. The Claims Specialist collaborates closely with external Smart Care Centers, clients, clinical teams, and internal operations to support efficient claims processing, reimbursement accuracy, and overall program performance.

Requirements

High School diploma or equivalent required.
Minimum of 3 years of experience in healthcare claims processing, billing, reimbursement, or a related healthcare operations role.
Strong understanding of medical claims processes, billing practices, and reimbursement methodologies.
Experience researching and resolving claims discrepancies, payment issues, and escalated claims concerns.
Strong attention to detail with the ability to manage multiple priorities in a fast-paced environment.
Effective problem-solving, organizational, and analytical skills.
Strong written and verbal communication skills with the ability to interact professionally with members, clients, and providers.
Proficiency in Microsoft Office Suite and claims processing systems or similar healthcare platforms, with the ability to learn new software/systems.
Ability to handle sensitive information in compliance with HIPAA confidentiality regulations.

Nice To Haves

Experience supporting Centers of Excellence (COE) programs, third-party administrators (TPAs), or self-funded health plans preferred.
Experience in member services or provider relations within a healthcare environment preferred.
Working knowledge of healthcare regulations, reimbursement guidelines, and industry standards preferred.
Experience working with claims reporting, reconciliation, or quality assurance processes preferred.

Responsibilities

Processes COE claims accurately and timely in accordance with established procedures and program requirements.
Reviews, researches, and resolves claims discrepancies, payment issues, and escalations with a high degree of accuracy.
Serves as a subject matter resource for claims investigations, billing questions, and reimbursement inquiries.
Coordinates with Smart Care Centers and clients to ensure timely and accurate claims adjudication and payment processing.
Supports members by addressing claims-related questions and concerns with a high level of professionalism service.
Conducts auditing, reconciliation, and quality review activities to ensure claims accuracy and reimbursement integrity.
Collaborates with COE Operations and Clinical teams to ensure claims workflows align with organizational standards and program requirements.
Maintains accurate claims documentation, payment records, and related reporting data.
Identifies trends, recurring issues, or system gaps and escalates appropriately to support resolution.
Contributes to continuous improvement initiatives to enhance claims processing efficiency, accuracy, and overall service delivery.
Leverages internal systems, reporting tools, and proprietary technologies, including AI-enabled solutions, to improve claims processing accuracy, streamline workflows, and enhance issue resolution.
Performs other projects, duties, and tasks, as assigned.