Claims Specialist (REMOTE)
Advantasure

Job Info

---

SUMMARY:

The Claims Specialist isresponsible for the coordination, development, and implementation of programs and strategies to improve service to customers in the area of claims processing.

RESPONSIBILITIES/TASKS:

• Conducts and coordinates investigations on all assigned claims to provide accurate facts for disposition, including on-site and desk investigation analysis.
• Analyzes intelligence information and makes determination for further investigation claims utilizing available resources.
• Follows established policies and procedures for conducting causation evaluations.
• Provides accurate and timely information to all internal and external stakeholders to address claim status and other inquiries, such as questions on subrogation recovery, reserve adequacy, and underwriting risks.
• Consistently monitors workflows to maximize efficiency.
• Maintains an acceptable level of service and customer satisfaction and retention.
• Analyzes trends and completes comprehensive and detailed reports.
• Assists with evaluation of training needs and designs and develops training modules, materials, and evaluations related to causation and subrogation for internal and external customers as needed.
• Applies up-to-date technical knowledge of investigative core functions.
• Delivers presentations as needed.
• Updates metric tracking documents monthly.
• Analyzes and interprets CMS changes and its potential impacts on claims processing.
• Develops system testing, scenarios, procedures, and controls and provides recommendation for ongoing improvement.
• Works with configuration on testing and system adjudication logic.

This position description identifies the responsibilities and tasks typically associated with the performance of the job. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION:

Bachelor's degree in a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.

EXPERIENCE:

Five years experience of progressive responsibility in health insurance claims processing with demonstrated technical knowledge that provides the necessary knowledge, skills, and abilities required.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Technical knowledge of insurance administration, claims management, or relevant insurance expertise.
• Knowledge of insurance claims processing rules and payment methodologies.
• Strong interpersonal and superior communication skills, including verbal and professional writing.
• Strong report preparation and presentation capability.
• Strong expertise in word processing and spreadsheets with knowledge of Microsoft applications.
• Ability to effectively exchange information clearly and concisely, present ideas, and respond to questions as appropriate, both in oral and written communications.

• Up-to-date technical knowledge to investigative core system functions.

• Ability to quickly make decisions and comprehend the consequences of various problem situations and take appropriate actions, and/or refer problems for necessary decision making.
• Ability to organize and prioritize multiple assignments.
• Ability to work within tight timelines when necessary.
• Ability to work with minimal supervision.
• Ability to identify workflow options to create and improve claims processing.
• Ability to continually exercise discretion and independent judgment in matters of significance.
• Ability to lead claim testing and communicate findings and resolutions.
• Knowledge of Ika systems.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.

This job has expired.