The Claims Specialist, under the direction of the Supervisor (with guidance from a Team Lead), is responsible for processing medical claims received from patients and/or HCPs across a broad product suite. An individual in this role is expected to meet or exceed productivity and quality standards. Associates possess a solid understanding of department processes, products, and operational tools/systems. This position utilizes ConnectiveRx and 3rd party systems to process claims and respond to inquiries from patients, physicians, pharmacies, and clients. The Associate may be assigned additional responsibilities by the Supervisor.
What you will do:
Verifies the accuracy and completeness of claim forms and attachments, such as EOBs, EOPs, SPPs, and pharmacy receipts. Information is entered into adjudication systems as required. Claims are paid or rejected based upon system adjudication and/or application of business rules external to the systems. Consults with Team Lead or Supervisor for complex claims or clarification of business rules. Obtains missing information by calling or writing customers using standard scripts or form letters. Based on volume, may also process claims and/or may answer phones
Refers requests for escalation as needed and engages other internal areas such as Program Management, IT and other Contact Center teams to resolve issues.
Provides input and feedback to Supervisor, Quality Management and Training (among others) to improve processes, procedures, and training.
Other projects and tasks as assigned
What we need from you:
High School or GED required
1+ years in a health care or case management setting
Experience working in pharmacy benefits, health care insurance, and/or medical billing a must
Health care or pharmaceutical experience, particularly in a medical claims processing, billing provider or insurance environment
Knowledge of EOB and EOP statements
Prior experience in a high-volume processing setting (i.e., doctor's office, claims processing department, etc.) a plus.
Will be trained to support programs, clients and/or job functions as appropriate
Experience with Third-Party systems (SelectRx, Pro-Care, FSV) (preferred)
Fluent in English/Spanish (a plus).
Knowledge of Medical Claims processing/billing coding
Communication skills: Uses writing effectively to create documents, uses correct spelling, grammar, and punctuation; Ability to convey written and verbal information in easy-to-understand language.
Customer Focus: High level of empathy and emotional intelligence; Focuses on opportunity to service patients with a high level of empathy
Detail Oriented: Achieves thoroughness and accuracy when accomplishing a task
Adaptability: Adapts to a variety of situations easily and effectively navigates situations
Problem Solve; Thinks critically, and problem-solves issues to resolution
Equal Opportunity Employer: This employer (hereafter the Company) is an equal opportunity employer and does not discriminate in recruitment, hiring, training, promotion, or other employment policies on the basis of age, race, sex, color, religion, national origin, disability, veteran status, genetic information, or any other basis that is prohibited by federal, state, or local law. No question in this application is intended to secure information to be used for such discrimination. In addition, the Company makes reasonable accommodation to the needs of disabled applicants and employees, so long as this does not create an undue hardship on the Company or threaten the health or safety of others at work. This application will be given every consideration, but its receipt does not imply that the applicant will be employed.
At ConnectiveRx we take the pain out of the prescription process. We don’t treat patients and we don’t make the medications that do. We use both innovation and human empathy to cut through mountains of red tape and create access to specialty medications for patients who have chronic disease—taking a process that can be expensive and difficult and making it as painless as possible. As one single partner, we connect patients with prescribed medications through hub services, affordability, awareness, and adherence solutions. The result? Happier patients who have a stronger connection to their medication brand. We've done this for hundreds of pharma companies and more than 530 drug brands. Let us facilitate great patient-to-drug experiences that make you shine. Learn more at connectiverx.com.