Claims Specialist 5254

What You'll Be Doing: As a Claims Specialist II, you'll play a critical role in ensuring claims are processed accurately, benefits are coordinated correctly, and members, providers, and internal stakeholders receive exceptional service.

Your responsibilities will include: Reviewing and processing medical claims with accuracy and attention to detail. Researching and resolving claim edits, denials, and payment discrepancies. Determining primary and secondary insurance coverage when members have multiple health plans. Applying Coordination of Benefits (COB) rules, including subscriber status, effective dates, plan types, and Medicare coordination guidelines. Updating claims and coverage records to ensure accurate claim adjudication. Investigating previously processed claims and making necessary benefit adjustments. Identifying and recovering overpayments through refunds, reprocessing, and recovery efforts. Communicating with members, providers, healthcare organizations, and insurance carriers to verify coverage and resolve claim issues. Reviewing quality audits and implementing corrections to maintain compliance and processing accuracy. Supporting special projects, process improvements, system updates, and departmental initiatives as needed.

Required Qualifications: High School Diploma or equivalent. Minimum of two (2) years of medical claims processing experience. Strong analytical and investigative skills with the ability to resolve complex claims issues. Excellent written and verbal communication skills. Ability to prioritize and manage multiple tasks in a fast-paced environment. Proficiency with claims processing systems and Microsoft Office applications.

Preferred Experience: Coordination of Benefits (COB) processing experience. Experience determining primary versus secondary insurance coverage. Knowledge of Medicare coordination and payer primacy guidelines. Experience researching claim discrepancies and resolving overpayments. Healthcare insurance, payer, or benefits administration experience. Why This Opportunity? This role offers the chance to work on challenging claims scenarios that require critical thinking, investigation, and problem-solving. You'll be part of a collaborative team focused on delivering quality service, maintaining financial accuracy, and supporting positive outcomes for members and providers. If you're looking for a position where your claims expertise can make a meaningful impact while continuing to grow your healthcare operations career, we encourage you to apply. Ideal Backgrounds Medical Claims Specialist Claims Examiner Coordination of Benefits Specialist Claims Analyst Healthcare Benefits Specialist Medical Billing & Claims Professional