Claims Processing Specialist

This role includes processing special claims that may involve manual review of actual treatment compared to authorized treatment, and adjudicating claims for specific client programs. The Claims Processing Specialist identifies and provides solutions for processing unique claims, refunds, overpayments, and underpayments.

Claims Processing Specialist



Job Summary

The Claims Processing Specialist identifies and provides solutions for processing unique claims, refunds, overpayments, and underpayments. This role includes processing special claims that may involve manual review of actual treatment compared to authorized treatment, and adjudicating claims for specific client programs.


Responsibilities

• Analyze authorizations compared to submitted claims.

• Process special claim payments for designated client programs.

• Process returned checks, personal checks, undeliverable checks, stale-dated checks, and requests for voids, stop-payments, and re-issues.

• Determine refund amounts and update the status of outstanding overpayments.

• Review monthly reports for outstanding overpayments and coordinate with finance on special issues.

• Review and handle special professional reviews, service issues, and quality complaints in coordination with the Special Correspondence Unit.

• Perform other related duties as requested or assigned.

Requirements

• High school diploma or GED.

• 2+ years of experience in claims processing or a closely related administrative function.

• Experience with claims adjudication;understanding of re-adjudication preferred.

• Dental claims processing experience preferred.

• Some customer service experience preferred.

• Proficiency in Microsoft Excel.

• Basic knowledge of accounting principles.

Skills

• High attention to detail and accuracy.

• Strong analytical and critical thinking skills.

• Excellent customer service and communication skills.

• Ability to independently prioritize work and follow established procedures.

• Ability to evaluate processes and take action to improve efficiency.

• Ability to confront difficult situations and make timely, appropriate decisions.

• Strong organizational skills with the ability to follow up and meet deadlines.

• Ability to collaborate effectively with others.

Summary Qualification

• High school diploma or GED with a minimum of 2 years of claims processing experience.

• Background in dental claims and claims adjudication, including re-adjudication, is highly desirable.

• Demonstrated proficiency in Excel and comfort working with numerical and financial data.

• Proven track record of maintaining accuracy, meeting deadlines, and managing multiple priorities.

• Strong interpersonal and customer service skills with the ability to handle complex or sensitive issues.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.