J OB D ES C R I PT IO N S UM MA R Y
The Claims Specialist supports the daily operations of the Claims department by performing routine review, reconciliation, and processing of healthcare claims in accordance with established policies, procedures, and plan benefits. This role focuses on executing defined processes, identifying basic claim issues, and ensuring accurate and timely claim handling. The position works under close to general supervision and escalates non-routine or complex issues to senior team members.
D U T I ES A ND R E S P O NS IB IL IT I E S
Claims Department Support
- Independently review, analyze, adjudicate, reconcile, and process complex healthcare claims in accordance with plan benefits, policies, regulatory requirements, and established procedures.
- Identify, research, adjudicate, and resolve complex claim errors, denials, discrepancies, failed transactions, overpayments, underpayments, and benefit interpretation issues, ensuring accurate correction and completion.
- Perform reconciliation and error resolution activities, including detailed review, correction, and validation of 835 and 837 transaction reports, invoice files, vendor files, and system reports.
- Document claim actions, research findings, benefit rationale, and resolution steps clearly and accurately within claims systems to support audit readiness and continuity of work.
- Communicate directly with providers, vendors, clients, internal departments, and leadership to obtain missing information, explain claim outcomes, resolve escalated issues, and support timely claim completion.
- Perform quality review activities, identify trends and root causes, provide feedback to team members, and recommend corrective actions to improve claim accuracy, timeliness, and compliance.
- Monitor and contribute to department productivity, quality, aging, and accuracy goals by prioritizing workloads, resolving aged inventory, and supporting service-level expectations.
- Support and help execute strategic claims initiatives, system enhancements, audits, special projects, and operational priorities as assigned by management.
Process Improvement
- Serve as a subject matter resource for complex, recurring, or unresolved claim issues by researching root causes, recommending solutions, and escalating only when additional leadership decision-making is required.
- Identify workflow gaps, recurring claim issues, and opportunities for process improvement; recommend and assist with implementing practical solutions that reduce errors and improve efficiency.
- Participating in or support testing, validation, and post-implementation review when system, benefit, vendor, or workflow changes are introduced.
- Partner with leadership and cross-functional teams to evaluate system and workflow changes, confirm operational readiness, and ensure updated procedures are consistently applied.
Process Documentation
- Review procedures, job aids, and training materials for accuracy and clarity; provide recommendations to leadership or trainers to improve consistency and reduce claim handling errors.
- Maintain compliance with documentation standards, data privacy requirements, HIPAA, plan provisions, internal controls, and audit expectations.
- Identify unclear instructions, documentation gaps, or inconsistent procedures and collaborate with leadership to clarify standards and update reference materials.
- Draft, update, and maintain process documentation, claim handling guidelines, and desk-level procedures when requested to support training, audit readiness, and consistent claim outcomes.
Other
- Utilize all capabilities to satisfy one mission - to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to
understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
- Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
- Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
- Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
- All other duties as assigned.
P H YS IC A L D E MA ND S /W OR K E N V I R O N ME N T
The physical demands and work environment described here represent those that an employee must meet to successfully perform this job's essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.
A C K N O W L E D G M E N T
Q UA L IF IC A T IO NS
- High school diploma or equivalent required; associate degree preferred and seven (7) years of experience in a Third-Party Administrator (TPA), health plan, or healthcare operations environment.
- Extensive knowledge of healthcare claims processing systems, plan benefits, and standard operating procedures.
- Ability to interpret Plan Documents or Summary Plan Descriptions (SPD) for the purpose of accurate claim adjudication and/or benefit determination.
- Advanced knowledge of Microsoft Excel and Office 365 tools.
- Strong attention to detail and ability to follow structured procedures.
- Effective written and verbal communication skills.
- Ability to meet productivity and quality expectations.
- Familiarity with electronic data interchange (EDI) transactions (e.g., 835 and 837 files), preferred.
- Strong attention to detail and ability to follow established procedures.
- Exceptional time management, multi-task, critical thinking, problem solving skills and ability to work under pressure and adapt to changing environment.
- Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
- Home router with wired Ethernet (wireless connections and hotspots are not permitted).
- A designated room for a home office or steps taken to protect company information.
- A functioning smoke detector, fire extinguisher, and first aid kit on site.