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Claims Specialist

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Plymouth Meeting, PA


Serve as the first line of assistance for members’ questions relating to post-service coverage of medical treatment or services. Assist members and their families in researching and resolving benefit claims issues, including billing discrepancies, coding errors, and insurance claims processing. Educate members on the components of their benefit plan coverage.

Essential Job Functions

Achieve/exceed Call Center Metrics (ASA -

•        Handle moderate to complex issues with minimal supervision such as dealing with irate members regarding unpaid claims and appeals, incorrect diagnosis and procedure coding, and payment negotiations on behalf of the members with provider offices and insurance carriers.

•        Regular contact with insurance carrier claims assistance, members, human resources departments, physician office managers, and hospital billing departments

•        Identify target resolution for all member calls and then, if possible, ensure cases close at or near the target resolution

•        Inform members of your plan of action, expected results and timeframes, then meet or exceed those timeframes

•        Build confidence in our services to encourage members to call back with future questions

•        Allay member anxiety and frustration

•        Add value to our services by going beyond the member’s initial request

•        Advocate for the member to receive coverage for the appropriate medical procedures, medications, and inpatient/outpatient treatment

•        Ensure member claims are processed correctly by the insurance carriers according to the member’s coverage

•        Research denied claims and verify proper coding

•        Facilitate proper coding with the providers office and the insurance carrier

•        Negotiate payment plans when possible between the member and provider’s office

•        Educate members on their insurance plan provisions

•        Assist PHA’s in claims related cases

•        Document all cases in case management system using the SOAP method (Subjective, Objective, Assessment, Plan) when appropriate

Job Requirements

•        Three to five years in medical billing, claims processing, appeals or pre-certification with an insurance carrier or third-party claims administrator

•        Ability to interpret Explanation of Benefits (EOB’s)

•        Knowledge of procedure and diagnosis coding (ICD-9, HCPCS, and CPT-4)

•        Familiarity with various types of health insurance coverage, coordination of benefits, and UCR fees

•        Understanding of insurance carrier claims processing

•        Knowledge of Durable Medical Equipment (DME) prescription procedures and plan riders

•        Strong desire to provide outstanding customer service

•        Ability to work as part of a team

•        Ability to educate callers

•        Strong listening and empathy

•        Ability to ask open-ended questions and uncover information

•        Effective communication skills to interact with members, physicians, and insurance carrier representatives

•        Special ability in mediating or negotiating compromises without alienating any party

•        Ability to calm anxious callers and defusing angry or hostile callers

•        Assertive, self-confident and resilient

•        Attention to detail and strong documentation skills

•        Proficient computer skills (Microsoft Office, Excel, Outlook, Adobe PDF, Internet Searches)

Company info

Health Advocate
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