Claims Specialist

Job Description

Claims Specialist US Remote Full time R11429 Why is Health Advocate a great place to work? For starters, Health Advocate employees enjoy helping people every single day. Employees are given the training they need to do their jobs well, and they work with supervisors and staff who are supportive and friendly. Employees have room to grow, and many of Health Advocate’s supervisors are promoted from within the company. Join our award winning team! Basic Function Responsible for handling escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members; handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner; handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.); ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations Major Accountabilities Claims Specialist Functions: Provide first-line assistance for member’s questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures Handle escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance*Research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue Assist members with dental related claims cases ensuring the claim is resolved or escalated in a timely manner Handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner Assist members with setting up payment arrangements and discounts which may include reaching out to healthcare providers to determine payment options Utilize a variety of resources to research and resolve billing issues (e.g., plan documents, summary plan documents, benefits summaries, open enrollment material interpretation of benefits, understanding of medical, dental vision and behavioral health coverage, etc.) Handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.) Assist with billing and claims adjudication process ensuring internal best practices are followed Remain current on knowledge of Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA), Health Spending Accounts (HSA), and benefits Summary Plan Descriptions (SPD) to resolve billing issues Assist team member with questions ensuring they have a clear understanding of workflow, subject manner and claims best practices Exercise exceptional customer service skills in an effort to optimize each contact with the member Ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations Know and support approved departmental and corporate policies and procedures relating to claims issues Based on department need, mentor new employees regarding claims process and internal procedures Participate in piloting departmental process improvements ensuring to provide any feedback to management Participate in systems user testing providing feedback in a timely manner Claims Research Assistance Assist in resolving routine program quality issues by identifying issue(s) and researching in a timely manner Research and evaluate billing issues to determine the possible cause of the error ensuring to assist the client with claims resubmission correct the issue As needed, contact healthcare providers to gather documentation (e.g., bills, medical records, etc.) ensuring to notify management if the request cannot be obtained Follow claims research through until resolution Document all claims issues thoroughly maintaining department files and appropriate databases Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels Team Interfaces/Customer Service Establish and maintain a professional relationship with internal/external customers, team members and department contacts Cooperate with team members to meet goals or complete tasks Provide quality customer service that exceeds customer expectations and improves level of service being provided Treat all internal/external customers, team members and department contacts with dignity/respect Escalate to supervisor any situation outside the employee’s control that could adversely impact the services being provided Mental and Physical Requirements This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers with a workspace that is free and clear of interruptions and distractions. The nature of the work in this position is sedentary and the incumbent will be sitting most of the time. Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day Related Duties as Assigned The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents Consequently, job incumbents may be asked to perform other duties as required Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above Please contact your local Employee Relations representative to request a review of any such accommodations MINIMUM QUALIFICATIONS Applicant for this job will be expected to meet the following minimum qualifications. Education High School Degree or GED required Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred. Experience Minimum of two years customer service, healthcare, or claims experience required. Other Basic Knowledge of MS Word and Excel required Must score acceptably on job related testing Ability to pass standardized interview ased on program may need to be bilingual in English, Spanish, etc. Knowledge of the following is preferred: Affordable Care Act (ACA) (Marketplace Navigation and Exchange plan review and comparison) Consolidated Omnibus Budget Reconciliation Act (COBRA) Medicare (Part A, Part B, Part D, Advantage and MediGap Plans) Compare and contrast benefit plan options (Open Enrollment, New Hire, Qualifying Life Event (QLE), and other Special Enrollment Periods) Group Benefits (Fully Insured vs. Self-Insured) Medical Benefits (CDHP/HDHP, PPO, POS, and HMO Plans) Pharmacy Benefits Dental Benefits Behavioral Health Benefits Vision Benefits FSA/HSA and HRA Benefits Long Term and Short Term Disability and Long Term Care Individual Health Plans Short Term Plans Claims Specialist US Remote US Remote Full time R11429 Why is Health Advocate a great place to work? For starters, Health Advocate employees enjoy helping people every single day. Employees are given the training they need to do their jobs well, and they work with supervisors and staff who are supportive and friendly. Employees have room to grow, and many of Health Advocate’s supervisors are promoted from within the company. Join our award winning team! Basic Function Basic Function Responsible for handling escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members; handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner; handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.); ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations Major Accountabilities Major Accountabilities Claims Specialist Functions: Claims Specialist Functions: Provide first-line assistance for member’s questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures Handle escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance*Research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue Assist members with dental related claims cases ensuring the claim is resolved or escalated in a timely manner Handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner Assist members with setting up payment arrangements and discounts which may include reaching out to healthcare providers to determine payment options Utilize a variety of resources to research and resolve billing issues (e.g., plan documents, summary plan documents, benefits summaries, open enrollment material interpretation of benefits, understanding of medical, dental vision and behavioral health coverage, etc.) Handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.) Assist with billing and claims adjudication process ensuring internal best practices are followed Remain current on knowledge of Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA), Health Spending Accounts (HSA), and benefits Summary Plan Descriptions (SPD) to resolve billing issues Assist team member with questions ensuring they have a clear understanding of workflow, subject manner and claims best practices Exercise exceptional customer service skills in an effort to optimize each contact with the member Ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations Know and support approved departmental and corporate policies and procedures relating to claims issues Based on department need, mentor new employees regarding claims process and internal procedures Participate in piloting departmental process improvements ensuring to provide any feedback to management Participate in systems user testing providing feedback in a timely manner Provide first-line assistance for member’s questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures Provide first-line assistance for member’s questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures Handle escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members Handle escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance*Research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance*Research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue Assist members with dental related claims cases ensuring the claim is resolved or escalated in a timely manner Assist members with dental related claims cases ensuring the claim is resolved or escalated in a timely manner Handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner Handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner Assist members with setting up payment arrangements and discounts which may include reaching out to healthcare providers to determine payment options Assist members with setting up payment arrangements and discounts which may include reaching out to healthcare providers to determine payment options Utilize a variety of resources to research and resolve billing issues (e.g., plan documents, summary plan documents, benefits summaries, open enrollment material interpretation of benefits, understanding of medical, dental vision and behavioral health coverage, etc.) Utilize a variety of resources to research and resolve billing issues (e.g., plan documents, summary plan documents, benefits summaries, open enrollment material interpretation of benefits, understanding of medical, dental vision and behavioral health coverage, etc.) Handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.) Handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.) Assist with billing and claims adjudication process ensuring internal best practices are followed Assist with billing and claims adjudication process ensuring internal best practices are followed Remain current on knowledge of Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA), Health Spending Accounts (HSA), and benefits Summary Plan Descriptions (SPD) to resolve billing issues Remain current on knowledge of Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA), Health Spending Accounts (HSA), and benefits Summary Plan Descriptions (SPD) to resolve billing issues Assist team member with questions ensuring they have a clear understanding of workflow, subject manner and claims best practices Assist team member with questions ensuring they have a clear understanding of workflow, subject manner and claims best practices Exercise exceptional customer service skills in an effort to optimize each contact with the member Exercise exceptional customer service skills in an effort to optimize each contact with the member Ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations Ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations Know and support approved departmental and corporate policies and procedures relating to claims issues Know and support approved departmental and corporate policies and procedures relating to claims issues Based on department need, mentor new employees regarding claims process and internal procedures Based on department need, mentor new employees regarding claims process and internal procedures Participate in piloting departmental process improvements ensuring to provide any feedback to management Participate in piloting departmental process improvements ensuring to provide any feedback to management Participate in systems user testing providing feedback in a timely manner Participate in systems user testing providing feedback in a timely manner Claims Research Assistance Claims Research Assistance Assist in resolving routine program quality issues by identifying issue(s) and researching in a timely manner Research and evaluate billing issues to determine the possible cause of the error ensuring to assist the client with claims resubmission correct the issue As needed, contact healthcare providers to gather documentation (e.g., bills, medical records, etc.) ensuring to notify management if the request cannot be obtained Follow claims research through until resolution Document all claims issues thoroughly maintaining department files and appropriate databases Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels Assist in resolving routine program quality issues by identifying issue(s) and researching in a timely manner Assist in resolving routine program quality issues by identifying issue(s) and researching in a timely manner Research and evaluate billing issues to determine the possible cause of the error ensuring to assist the client with claims resubmission correct the issue Research and evaluate billing issues to determine the possible cause of the error ensuring to assist the client with claims resubmission correct the issue As needed, contact healthcare providers to gather documentation (e.g., bills, medical records, etc.) ensuring to notify management if the request cannot be obtained As needed, contact healthcare providers to gather documentation (e.g., bills, medical records, etc.) ensuring to notify management if the request cannot be obtained Follow claims research through until resolution Follow claims research through until resolution Document all claims issues thoroughly maintaining department files and appropriate databases Document all claims issues thoroughly maintaining department files and appropriate databases Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels Team Interfaces/Customer Service Team Interfaces/Customer Service Establish and maintain a professional relationship with internal/external customers, team members and department contacts Cooperate with team members to meet goals or complete tasks Provide quality customer service that exceeds customer expectations and improves level of service being provided Treat all internal/external customers, team members and department contacts with dignity/respect Escalate to supervisor any situation outside the employee’s control that could adversely impact the services being provided Establish and maintain a professional relationship with internal/external customers, team members and department contacts Establish and maintain a professional relationship with internal/external customers, team members and department contacts Cooperate with team members to meet goals or complete tasks Cooperate with team members to meet goals or complete tasks Provide quality customer service that exceeds customer expectations and improves level of service being provided Provide quality customer service that exceeds customer expectations and improves level of service being provided Treat all internal/external customers, team members and department contacts with dignity/respect Treat all internal/external customers, team members and department contacts with dignity/respect Escalate to supervisor any situation outside the employee’s control that could adversely impact the services being provided Escalate to supervisor any situation outside the employee’s control that could adversely impact the services being provided Mental and Physical Requirements Mental and Physical Requirements This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers with a workspace that is free and clear of interruptions and distractions. The nature of the work in this position is sedentary and the incumbent will be sitting most of the time. Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers with a workspace that is free and clear of interruptions and distractions. This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers with a workspace that is free and clear of interruptions and distractions. The nature of the work in this position is sedentary and the incumbent will be sitting most of the time. The nature of the work in this position is sedentary and the incumbent will be sitting most of the time. Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software/hardware continuously throughout the work day Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day Essential mental functions of this position include concentrating on tasks, reading information, and verbal/written communication to others continuously throughout the work day Related Duties as Assigned Related Duties as Assigned The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents Consequently, job incumbents may be asked to perform other duties as required Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above Please contact your local Employee Relations representative to request a review of any such accommodations The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents Consequently, job incumbents may be asked to perform other duties as required Consequently, job incumbents may be asked to perform other duties as required Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above Please contact your local Employee Relations representative to request a review of any such accommodations Please contact your local Employee Relations representative to request a review of any such accommodations MINIMUM QUALIFICATIONS MINIMUM QUALIFICATIONS Applicant for this job will be expected to meet the following minimum qualifications. Education Education High School Degree or GED required Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred. High School Degree or GED required High School Degree or GED required High School Degree or GED required Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred. Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred. Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred. Experience Experience Minimum of two years customer service, healthcare, or claims experience required. Minimum of two years customer service, healthcare, or claims experience required. Minimum of two years customer service, healthcare, or claims experience required. Other Other Basic Knowledge of MS Word and Excel required Must score acceptably on job related testing Ability to pass standardized interview ased on program may need to be bilingual in English, Spanish, etc. Basic Knowledge of MS Word and Excel required Basic Knowledge of MS Word and Excel required Must score acceptably on job related testing Must score acceptably on job related testing Ability to pass standardized interview Ability to pass standardized interview ased on program may need to be bilingual in English, Spanish, etc. ased on program may need to be bilingual in English, Spanish, etc. Knowledge of the following is preferred: Knowledge of the following is preferred: Affordable Care Act (ACA) (Marketplace Navigation and Exchange plan review and comparison) Consolidated Omnibus Budget Reconciliation Act (COBRA) Medicare (Part A, Part B, Part D, Advantage and MediGap Plans) Compare and contrast benefit plan options (Open Enrollment, New Hire, Qualifying Life Event (QLE), and other Special Enrollment Periods) Group Benefits (Fully Insured vs. Self-Insured) Medical Benefits (CDHP/HDHP, PPO, POS, and HMO Plans) Pharmacy Benefits Dental Benefits Behavioral Health Benefits Vision Benefits FSA/HSA and HRA Benefits Long Term and Short Term Disability and Long Term Care Individual Health Plans Short Term Plans Affordable Care Act (ACA) (Marketplace Navigation and Exchange plan review and comparison) Affordable Care Act (ACA) (Marketplace Navigation and Exchange plan review and comparison) Consolidated Omnibus Budget Reconciliation Act (COBRA) Consolidated Omnibus Budget Reconciliation Act (COBRA) Medicare (Part A, Part B, Part D, Advantage and MediGap Plans) Medicare (Part A, Part B, Part D, Advantage and MediGap Plans) Compare and contrast benefit plan options (Open Enrollment, New Hire, Qualifying Life Event (QLE), and other Special Enrollment Periods) Compare and contrast benefit plan options (Open Enrollment, New Hire, Qualifying Life Event (QLE), and other Special Enrollment Periods) Group Benefits (Fully Insured vs. Self-Insured) Group Benefits (Fully Insured vs. Self-Insured) Medical Benefits (CDHP/HDHP, PPO, POS, and HMO Plans) Medical Benefits (CDHP/HDHP, PPO, POS, and HMO Plans) Pharmacy Benefits Pharmacy Benefits Dental Benefits Dental Benefits Behavioral Health Benefits Behavioral Health Benefits Vision Benefits Vision Benefits FSA/HSA and HRA Benefits FSA/HSA and HRA Benefits Long Term and Short Term Disability and Long Term Care Long Term and Short Term Disability and Long Term Care Individual Health Plans Individual Health Plans Short Term Plans Short Term Plans