Claims Specialist - Miami, FL

Morgan White Group•Coral Gables, FL

1d•Onsite

About The Position

The Claims Specialist reports to the Claims Department Manager in the MWG-Administrators TPA Division. The position is a non-exempt, hourly role and is located at 75 Valencia Avenue, Coral Gables, FL 33134. The Claims Specialist will review claims for reporting information in a spreadsheet or software and communicate with the TPA Manager and Claims Manager daily as well as possibly interacting with groups, claimants, outside carriers, and agents. To perform the job successfully, the employee must be able to perform each essential duty satisfactorily. The requirements listed here are representative of the knowledge, skill, and ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Requirements

High School Diploma or GED required
Must have 1-2 years of previous insurance claims experience
Must have excellent computer skills and be knowledgeable in MS Outlook, Windows, Excel, and Word.
Must be able to learn and be proficient with the software used in the TPA department.
Must possess strong time management, organizational, problem solving, and customer service skills.
Must be able to work well under pressure with multiple priorities and meet deadlines while maintaining attention to details.
Must be able to read, write, and speak English
Must be able to work as scheduled.
Must possess sight and hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of the position as stated above can be fully met.
Must be able to bend, stretch, reach, and sit or stand at a desk during 85% of the workday.
Must be able to lift, stoop, and carry small equipment items and supplies, possibly weighing up to 20lbs.

Nice To Haves

Associates or bachelor's degree is preferred.
previous experience with electronic data interchange (EDI) of files is preferred.
Spanish is a plus.

Responsibilities

Perform review and adjudication of insurance claims.
Utilize MWG Administrators Policy Administration System and Claims Management Software to verify eligibility and review member accounts based on the policy assigned.
Input data into MWG Administrators Claims Management Software.
Handle incoming mail, provider appeals, inquiries, and racers.
Review member correspondence and process or direct to the appropriate department.
Maintain quality customer service by following customer service best practices and being responsive.
Perform periodic audits on individual and group policies to verify claims have been paid correctly.
Protect operations by keeping claims information confidential.
Ensure legal compliance by following company policies, procedures, and guidelines.
Identify escalated issues and handoff to supervisor.
Meet or exceed all performance metrics.
Be knowledgeable and have a clear understanding of the business processes within MWG including internal departments, insurance carriers, brokers/agents, and group contacts.
Perform other duties as assigned by the Department Manager.