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Medical Claim Specialist

Remote: 
Full Remote
Contract: 
Experience: 
Mid-level (2-5 years)
Work from: 

Offer summary

Qualifications:

High School Graduate or equivalent, Minimum of two years medical claims analysis experience, Knowledge of CPT and ICD-10 coding, Strong analytical skills and computer knowledge, Prior experience with Third-party Administrator preferred.

Key responsabilities:

  • Process Medical and Dental claims in QicLink system
  • Review, analyze, and determine payment for claims
  • Ensure compliance with privacy and security laws
  • Authorize payment or denial after independent analysis
  • Support other Claim Specialists and attend training classes
Allied Benefit Systems, LLC logo
Allied Benefit Systems, LLC Unicorn https://www.alliedbenefit.com/
501 - 1000 Employees
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Job description

ASSISTANT CLAIM SPECIALIST

Position Summary

The Assistant Claim Specialist is an entry level position for claim processing. This person will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical and dental claims, as well as various types of invoices, based upon specific knowledge and application of each client’s customized plan(s).

Essential Functions

  • Process Medical and Dental claims as well as invoices, in the QicLink system.
  • Read, analyze, understand, and ensure compliance with clients’ customized plans
  • Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
  • Independently review, analyze and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud.
  • Review, analyze and add applicable notes in the QicLink system.
  • Review billed procedure and diagnosis codes on claims for billing irregularities.
  • Analyze claims for billing inconsistencies and medical necessity.
  • Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
  • Review Workflow Manager daily to document and release pended claims, if applicable.
  • Review Pend and Suspend claim reports to finalize all claim determinations timely.
  • Assist and support other Claim Specialists as needed and when requested.
  • Attend continuing education classes as required, including but not limited to HIPAA training.

EDUCATION

  • High School Graduate or equivalent
  • Continuing education in all areas affecting group health and welfare plans is required.

Experience & Skills

  • Applicants must have a minimum of two (2) years of medical claims analysis experience (Medicare/Medicaid does not count towards the experience).
  • Prior experience with a Third-party Administrator is highly preferred.
  • Applicants must have knowledge of CPT and ICD-10 coding.
  • Applicants must have strong analytical skills and knowledge of computer systems.
  • Applicants must demonstrate the desire to assist the Team with exceeding all established goals.
  • Prior experience with dental and vision processing is preferred, but not required.

COMPETENCIES

  • Job Knowledge
  • Time Management
  • Accountability
  • Communication
  • Initiative
  • Customer Focus

PHYSICAL DEMANDS

  • Office setting and ability to sit for long periods of time.

WORK ENVIRONMENT

  • Remote

Required profile

Experience

Level of experience: Mid-level (2-5 years)
Spoken language(s):
English
Check out the description to know which languages are mandatory.

Other Skills

  • Decision Making
  • Analytical Skills
  • Communication
  • Accountability
  • Problem Solving
  • Time Management

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