Job Title: Medical Claims Specialist
Reports To: Medical Claims Manager
FLSA Status: Non-Exempt
Summary: Responsible for working in a fast paced environment and having strong interpersonal and communication skills, attention to details, outstanding ability to multi-task and prioritize, and strong analytical skills. Performs administrative tasks related to client health premiums and out of pocket medical expenses, interact with clients to provide information in response to inquiries about products and services, and handle and resolve complaints by performing the following duties.
Duties and Responsibilities include the following.
1. Processes or adjust medical insurance claims in accordance with policies and procedures.*
2. Answers phones and respond to client inquiries related to payments made on their behalf to medical providers.*
3. Answers phones and responds to medical provider inquiries related to payments made or due to their office on their behalf of program clients.*
4. Makes outgoing calls to medical providers and insurance companies.*
5. Responsible for having the ability to read explanation of benefits and healthcare terminology.*
6. Identifies, researches, resolves claim issues, and requests for additional documentation.*
7. Promotes teamwork and service delivery success.*
8. Ensures contractual performance guarantees related to payment processing timeliness and accuracy are met.*
9. Ensures contractual performance guarantees related to various means of client communications are met such as phone, email, and mail.*
10. Processes health insurance premium payments for clients.*
11. Processes medical payments for clients.*
12. Assists in the client appeals process.*
13. Creates and updates financial batch records for processing by accounting.*
14. Audits payment files and outgoing payments and checks accuracy of figures calculation.*
15. Manages workflow for the team to ensure service levels are achieved.*
16. Manages call logs.*
17. Works with client’s that have high medical utilization.*
18. Recommends process improvements.*
19. Performs other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
To perform this job successfully, an individual should have knowledge of word processing software, spreadsheet software, internet software, time keeping system, and medical coding strongly preferred but not required.
Associate's degree (A. A. / A. S.) or equivalent from two-year college or technical school; or three to four years related experience and/or training; or equivalent combination of education and experience.
Knowledge of medical insurance practices including enrollment, payment terms related to insurance premiums and out of pocket expenses, benefits coordination with other insurance coverage, and ensuring payer of last resort.
Certificates and Licenses:
Medical coding certification or equivalent experience
Knowledge, Skills, and Other Abilities:
· Speaking which includes talking to others to convey information effectively
· Knowledge of medical insurance practices including enrollment, payment terms related to insurance premiums and out of pocket expenses, benefits coordination with other insurance coverage, and ensuring payer of last resort
· Analytic Skills which includes the ability to review and understand payment and account history
· Active Listening which includes giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times
· Service Orientation which includes actively looking for ways to help people
· Writing which includes communicating effectively in writing as appropriate for the needs of the audience
· Reading Comprehension which includes an understanding written sentences and paragraphs in work related documents
· Proficiency with all MS Office applications including Microsoft Excel, Microsoft Word, and Microsoft Outlook
· Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on timely analyses
· Precise attention to detail
The above is intended to provide general guidance regarding the responsibilities of the position. It is not intended to be an all-encompassing definition of what the position entails and may be changed at the discretion of Senior Management at any time.
PAI is an equal employment and affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, religion, age, national origin, disability, veteran status, sexual orientation, gender identity or expression, marital status, ancestry or citizenship status, genetic information, pregnancy status or any other characteristic protected by law.
We are passionate about improving access to healthcare and human services by working together to solve fundamental issues for people in need.
By combining our unique expertise, our team approach and technology systems, PAI successfully administers various subsidy programs such as senior prescription drug subsidies, Ryan White subsidies, reinsurance and risk pool programs.
Role: Medical Claims Specialist
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