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.

Onsite Monday - Friday 11:30am-8pm

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.