- Review and adjudicate all types of claims designated as "production claims", meeting production and quality goals.
- Review, investigate, and apply all necessary criteria to determine validity of claim.
- Understand the Anthem JAA workflow and apply JAA processing procedures, rules, and guidelines to adjudicate JAA claims.
- Apply benefit plan rules and processing guidelines to pay, pend, or deny claims.
- Manage and follow up timely on all pending claims and correspondence, including review of patient claim history.
- Prepare and generate accurate claim EOB messages and correspondence.
- Review and determine eligibility and coverage for specific group/plan.
- Research claim problems and take necessary actions to resolve.
- Utilize training and on-line documentation to keep up to date on processing guidelines, insurance principles, DOL rules and regulations, and benefit plan rules.
- Update claims system with applicable claim/and patient notes.
- Perform COB, No-fault, Pre-existing, and other claim investigations.
- Contact employers, providers, participants, as necessary.
- Identify correct providers, PPOs, and ensure that appropriate pricing is obtained.
- Perform non-complex claim adjustments, including handling of customer service referrals and take appropriate steps to initiate adjustments on JAA claims.
- Troubleshoot utilization review and medical necessity related issues utilizing AMM or other UR vendor's website information, and route claims for review accordingly.
- Utilize Claim Workflow system for work assignments, routing, and follow up.
- Handle other claim-related duties, projects, and assignments as assigned, including the handling of claim exceptions and provider not found claims.
- One to two years of college or equivalent experience.
- Minimum one years' claims experience.
- Familiarity with Eldorado Software is a plus.
- Medical billing and/or AMA coding experience preferred.
- Data Entry experience or equivalent type work using keyboard/PC.
-
Claims Specialist
2 weeks ago
FRESH DIRECT, LLC Bronx, United StatesClaims Specialist **(CONTRACT)** · Under the direction of an assigned Manager, perform a variety of specialized and analytical duties involved in auto and Workers Compensation claims; monitor, coordinate and process; maintain case history documentation; contact and interview inju ...
-
Claims Specialist
3 weeks ago
Expedite Technology Solutions New York, United StatesAdjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies. · - Resolve complex, severe exposure claims, using high service oriented file handling. · - Pay and process claims within designated authority level. · - E ...
-
Claims Specialist
1 week ago
Combined Insurance Jersey City, United StatesThe Claim Specialist, under moderate direction from the manager, investigates and settles claims promptly, equitably, and within established best practices guidelines. · **Scope** · - Responsible for investigating; settling high exposure, high risk Employment Practices Claims. · ...
-
Claims Review Specialist
2 weeks ago
NYC Careers Manhattan, United States**CLAIMS REVIEW SPECIALIST**: · - Apply**CLAIMS REVIEW SPECIALIST**: · - Agency: HRA/DEPT OF SOCIAL SERVICES · - Posted on: 04/18/2024- Job type: Full-time · Location · MANHATTAN · - Title Classification: Exam may be required · Department · Office Of Revenue/Admin-NM · - Salary r ...
-
Claims Specialist I
5 days ago
Nationwide New York, United StatesIf you're passionate about helping people protect what matters most to them, as well as innovating and simplifying processes and operations to provide the best customer value, then Nationwide's Property and Casualty team could be the place for you At Nationwide, "on your side" go ...
-
Claims Specialist Ii
2 days ago
Aon Corporation New York, United StatesPosting Description: · **Do you have experience in claims adjudication and enjoy resolving issues for clients? If you'd like to grow your experience with a globally respected firm, this may be the next step in your career** · **How this role is different**: · Our leaders pride th ...
-
Claims Specialist Ii
3 days ago
Aon Corporation New York, United StatesPosting Description: · **Do you have experience in claims adjudication and enjoy resolving issues for clients? If you'd like to grow your experience with a globally respected firm, this may be the next step in your career** · **How this role is different**: · Our leaders pride th ...
-
Claims Specialist
3 weeks ago
FreshDirect Bronx, United StatesDuties will include handling workers compensation and auto claims including bodily injury, physical damage, and property damage/liability claims Serve as a technical resource concerning Workers Compensation and auto claims; respond to inquiries and p Claims Specialist, Claims, Wo ...
-
Claims Specialist, Level Ii
3 weeks ago
NYC Careers Manhattan, United States**Claims Specialist, Level II - Property Damage**: · - Apply**Claims Specialist, Level II - Property Damage**: · - Agency: OFFICE OF THE COMPTROLLER · - Posted on: 04/13/2024- Job type: Full-time · Location · MANHATTAN · - Title Classification: Exam may be required · Department · ...
-
Insurance Claims Specialist Construction
1 week ago
Dragonetti Brothers Landscaping Brooklyn, United States**Insurance Claims Specialist Construction (60% of position)** · Further responsibilities include obtaining favorable results through investigating, evaluating, reserving, reporting, recommending, negotiating, and managing litigation. · **Required Skills**: · - 5 years minimum re ...
-
Claim Specialist- Field Property Inspection
3 weeks ago
State Farm Mutual Automobile Insurance Company New York, United StatesSyracuse, New York; Watertown, New York · - Claims and Investigation · - Regular Full Time · - 37209 · **Job Description**: · **Overview** · Build your career at one of the top companies for professional growth in the U.S. Khakis optional. · At State Farm we invest in our employe ...
-
Claims Resolution Specialist III Hybrid
3 weeks ago
UROPARTNERS LLC Westchester, United StatesJob Description · Job DescriptionDescription:**This position is hybrid/remote if in the Chicago/Westchester area** · GENERAL SUMMARY · The Claim Resolution Specialist III focuses on following up and resolving claims submitted to third-party insurance payers. This includes claims ...
-
Claims Resolution Specialist III Hybrid
3 weeks ago
UROPARTNERS LLC Westchester, United StatesJob Description · Job DescriptionDescription:**This position can be fully remote or hybrid/remote if in the Chicago/Westchester area** · GENERAL SUMMARY · The Claim Resolution Specialist III focuses on following up and resolving claims submitted to third-party insurance payers. T ...
-
Medical Claims Specialist
5 days ago
Stafford Communications New Rochelle, United StatesJob Title: Medical Claims Specialist - RemoteStafford Communications is uniquely different. Stafford Communications, a division of Premier BPO specializes in customer service, compliance and marketing in support of many prestigious brands in in pharmaceutical, healthcare, food, c ...
-
Short Term Disability Claims Specialist
4 days ago
MetLife New York, United StatesCity/Cities- Bloomfield, Oriskany- State(s)- Connecticut, New York- Country- United States- Working Schedule- Full-Time- Commutable Distance Required- Yes- Relocation Assistance Available- No- Posted Date- 02-May-2024- Job ID- 2567**Description and Requirements**: · Short Term Di ...
-
Claims Specialist
3 weeks ago
Tandym Group Flushing, United StatesA health services network in New York is currently seeking a new Claims Specialist for a promising opportunity with their growing team in Flushing. · Responsibilities: · The Claims Specialist will: · Be responsible for reviewing claims processed by the outside vendor, including ...
-
Charge/claims Edits Specialist I #full Time
1 week ago
61st Street Service Corp New York, United States Full time**Job Summary**: · Charge/Claim Edits Specialist I is responsible for reviewing and performing appropriate actions on charges and claims. This position is the point person within the department responsible for making all charge and claim corrections. The individual in this role w ...
-
Claims Specialist
2 weeks ago
LHH New York, United StatesLHH Recruitment Solutions is seeking a Claims Specialist for a great plaintiff law firm. This opportunity is full time and hybrid out of New York, NY. · Hours: 9:30am - 5:30pm, overtime when necessary · Responsibilities · Format documents and communications for clients; review d ...
-
Claim Specialist
3 weeks ago
City of New York New York, United StatesJob Description · The NYC Department of Environmental Protection (DEP) protects public health and the environment by supplying clean drinking water, collecting and treating wastewater, and reducing air, noise, and hazardous materials pollution. DEP is the largest combined munici ...
-
Claims Specialist
1 week ago
Experis Livingston, United StatesOur client is seeking a Claims Specialist to join their team. The ideal candidate will have excellent interpersonal, written, and oral communication skills which will align successfully in the organization. · Job Title: Claims Specialist · Location: Livingston, NJ · Pay : $ ...
Medical Claims Specialist - Yonkers, United States - Stafford Communications
Description
Job Title: Medical Claims Specialist - RemoteStafford Communications is uniquely different. Stafford Communications, a division of Premier BPO specializes in customer service, compliance and marketing in support of many prestigious brands in in pharmaceutical, healthcare, food, consumer packaged goods and beauty care companies - ensuring their customer service initiatives are aligned to their marketing programs.
Job Summary:
Medical Claims Specialist - Remote is responsible for the review, investigation, decision making, and processing of production claim types, and all related claim functions and activities. Production claims are those claims under $5,000.
Essential Duties and Responsibilities:
•Knowledge of insurance and medical terminology.
•High level of keyboard/PC skills.
•Excellent oral and written communication skills.
•Good judgment and decision-making abilities.
•Good analytical and math skills.
•Good interpersonal skills and willingness to assist others.
•Basic knowledge of Word and Excel.
Pay, benefits and more:
We are eager to attract the best, so we offer competitive compensation and a generous benefits package, including full health insurance (medical, dental and vision), 401(k), life insurance, disability and more.