Claims Specialist

A s the Claims Specialist, you will coordinate activities critical to the successful completion of clinical reviews projects. You will support programs by monitoring requests, liaising with clinical partners, managing provider and contractor interactions, tracking deliverables and deadlines, and develop project frameworks to support interdisciplinary and interagency communications. Duties include by are not limited to:

Monitor appeal/dispute status and communication received on client portals.

Conduct initial eligibility reviews and recommend course of action to internal team and department management.

Track and assign cases using commercial off-the-shelf and custom software applications.

Monitor and measure key performance indicators.

Identify barriers and roadblocks in work processes, recommend solutions to solve problems, and execute approved solutions.

Routinely present case/project status in huddles and scrums while using an agile, iterative approach to implementation and data presentation.

Schedule regular team status meetings and record decisions (e.g., assigned tasks and next steps).

Prepare billing invoices at conclusion of cases, submit to the Finance department, and liaise with accounting to track and trend payments.

QUALIFICATIONS :

Knowledge and experience with collaborative project management software, electronic documents, and design.

Ability to problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.

Excellent written and verbal skills including phone manner.

Ability to work independently with little supervision.

Ability and desire to be flexible, innovative, and creative while multi-tasking.

Ability to meet deadlines in time sensitive environment.

EDUCATION & EXPERIENCE :