Job Details

POSITION SUMMARY

The Claims Specialist reviews, analyzes, and make determinations regarding payment, partial payment, or denial of medical, vision, and dental claims, based upon specific knowledge and application of the client's customized plan. Assist with specific tasks as needed and assigned by the Management Team and support of the Virtual Insurance Claim Team.

ESSENTIAL FUNCTIONS

• Read, analyze, understand, and ensure compliance with clients' customized plans. (A plan may be hundreds of pages or more).
• Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
• Request, review and analyze any physician notes, hospital records or police reports.
• Interview claimants, physicians, hospitals and other third parties for additional information.
• Consult with other professionals such as attorneys, nurses, physicians and auditors who can offer additional evaluation of a claim.
• Independently review, analyze, and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physicians and hospitals; and 3) fraud.
• Process claims in the QicLink System.
• Review, analyze and add applicable notes to the QicLink System.
• Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Review and analyze specific procedure and diagnosis codes for medical necessity.
• Determine whether claimant's plan covers the claim submitted and how much money, if any, should be paid.
• Authorize payment, partial payment or denial of claim based upon individual investigation and analysis. (On a yearly basis, responsible for determining claims payments totaling millions of dollars on behalf of Allied's clients).
• Review Workflow Manager daily to document and release pended claims.
• Review Pended Claim Reports and close out pended claims for which no response has been received.
• Review Suspended Claim Reports and follow up on open issues.
• Process Adjustment Claims when necessary, due to corrected claims as well as applying refunds in the QL system.
• Assist and support other claims adjusters as needed and when requested.
• Attend continuing education classes as required, including but not limited to HIPAA training.
• Other duties as assigned.

EDUCATION

• High School Diploma required, and College Preferred.
• Continuing education in all areas affecting group health and welfare plans is required.

EXPERIENCE AND SKILLS

• Applicants must have a minimum of five (5) years of medical claims analysis and adjudication experience (including dental and vision claims analysis).
• Applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-10 coding terminology.
• Applicants must demonstrate the desire to assist the Team with exceeding all established goals.
• Prior experience in Adjustment Processing is preferred but not required.

POSITION COMPETENCIES

• Job Knowledge

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

PHYSICAL DEMANDS

• This is a standard desk role that requires extended periods of sitting and computer work

WORK ENVIRONMENT

• Remote

Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive.

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life and Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.

Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.