Claims Specialist

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    "jobTitle": "Claims Specialist",
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    "description": "<p><span style=\"font-family:'Times New Roman',serif\"><strong><span style=\"font-family:Arial,sans-serif\">POSITION SUMMARY</span></strong></span></p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">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&rsquo;s customized plan. Assist with specific tasks as needed and assigned by the Management Team and support of the Virtual Insurance Claim Team.&nbsp;</span></span></p>\n\n<p><strong><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">This opportunity is scheduled to begin on June 22 and includes a paid six‑week training period. To support a smooth and successful onboarding experience, participants are encouraged to plan for limited or no time off during the training phase.</span></span></strong></p>\n\n<p>&nbsp;</p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><strong><span style=\"font-family:Arial,sans-serif\">ESSENTIAL FUNCTIONS&nbsp;</span></strong></span></p>\n\n<ul>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Read, analyze, understand, and ensure compliance with clients&rsquo; customized plans</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Request, review and analyze any physician notes, hospital records or police reports</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Interview claimants, physicians, hospitals and other third parties for additional information</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Consult with other professionals such as attorneys, nurses, physicians and auditors who can offer additional evaluation of a claim</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Independently review, analyze, and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physicians and hospitals; and 3) fraud</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Process claims in the QicLink System</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Review, analyze and add applicable notes to the QicLink System</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Review billed procedure and diagnosis codes on claims for billing irregularities</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Review and analyze specific procedure and diagnosis codes for medical necessity</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Determine whether claimant&rsquo;s plan covers the claim submitted and how much money, if any, should be paid</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">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&rsquo;s clients)</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Review Workflow Manager daily to document and release pended claims&nbsp;</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Review Pended Claim Reports and close out pended claims for which no response has been received</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Review Suspended Claim Reports and follow up on open issues</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Process Adjustment Claims when necessary, due to corrected claims as well as applying refunds in the QL system</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Assist and support other claims adjusters as needed and when requested</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Attend continuing education classes as required, including but not limited to HIPAA training</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Other duties as assigned</span></span></li>\n</ul>\n\n<p>&nbsp;</p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><strong><span style=\"font-family:Arial,sans-serif\">EDUCATION</span></strong></span></p>\n\n<ul>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">High School Diploma required, and College Preferred.</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Continuing education in all areas affecting group health and welfare plans is required.</span></span></li>\n</ul>\n\n<p>&nbsp;</p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><strong><span style=\"font-family:Arial,sans-serif\">EXPERIENCE AND SKILLS&nbsp;</span></strong></span></p>\n\n<ul>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Applicants must have a minimum of five (5) years of medical claims analysis and adjudication experience (including dental and vision claims analysis)&nbsp;</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-10 coding terminology&nbsp;</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Applicants must demonstrate the desire to assist with exceeding all established goals</span></span></li>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Prior experience in Adjustment Processing is preferred but not required</span></span></li>\n</ul>\n\n<p>&nbsp;</p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><strong><span style=\"font-family:Arial,sans-serif\">COMPETENCIES</span></strong></span></p>\n\n<ul>\n\t<li><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">Accountability</span></span></span></li>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">Analytical Thinking</span></span></span></li>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">Collaboration</span></span></span></li>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">Communication</span></span></span></li>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">Customer Focus</span></span></span></li>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">Functional Expertise</span></span></span></li>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">Initiative</span></span></span></li>\n</ul>\n\n<p style=\"margin-left:48px\">&nbsp;</p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><strong><span style=\"font-family:Arial,sans-serif\">PHYSICAL DEMANDS</span></strong></span></p>\n\n<ul>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\"><span style=\"color:#000000\">This is a standard desk role that requires extended periods of sitting and computer work</span></span></span></li>\n</ul>\n\n<p>&nbsp;</p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><strong><span style=\"font-family:Arial,sans-serif\">WORK ENVIRONMENT&nbsp;</span></strong></span></p>\n\n<ul>\n\t<li><span style=\"font-family:Calibri,sans-serif\"><span style=\"font-family:Arial,sans-serif\">Remote</span></span></li>\n</ul>\n\n<p>&nbsp;</p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">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</span><span style=\"font-family:Calibri,sans-serif\">.</span></span></p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">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.</span></span></p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Compensation is not limited to base salary.&nbsp; 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.</span></span></p>\n\n<p><span style=\"font-family:'Times New Roman',serif\"><span style=\"font-family:Arial,sans-serif\">Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time.&nbsp; 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.&nbsp; It is at the Company&#39;s discretion to determine what pay is provided to a candidate within the range associated with the role.</span></span>&nbsp;</p>\n",
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Additional functions and requirements may be assigned by supervisors as deemed appropriate.\\n\\nCompensation is not limited to base salary.&nbsp; 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.\\n\\nAllied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time.&nbsp; 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.&nbsp; It is at the Company&#39;s discretion to determine what pay is provided to a candidate within the range associated with the role.&nbsp;\\nQualifications\",\"responsibilities\":\"POSITION SUMMARY\\n\\nThe 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&rsquo;s customized plan. Assist with specific tasks as needed and assigned by the Management Team and support of the Virtual Insurance Claim Team.&nbsp;\\n\\nThis opportunity is scheduled to begin on June 22 and includes a paid six‑week training period. To support a smooth and successful onboarding experience, participants are encouraged to plan for limited or no time off during the training phase.\\n\\n&nbsp;\\n\\nESSENTIAL FUNCTIONS&nbsp;\\n\\n\\n\\tRead, analyze, understand, and ensure compliance with clients&rsquo; customized plans\\n\\tLearn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto\\n\\tRequest, review and analyze any physician notes, hospital records or police reports\\n\\tInterview claimants, physicians, hospitals and other third parties for additional information\\n\\tConsult with other professionals such as attorneys, nurses, physicians and auditors who can offer additional evaluation of a claim\\n\\tIndependently review, analyze, and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physicians and hospitals; and 3) fraud\\n\\tProcess claims in the QicLink System\\n\\tReview, analyze and add applicable notes to the QicLink System\\n\\tDocument all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com\\n\\tReview billed procedure and diagnosis codes on claims for billing irregularities\\n\\tReview and analyze specific procedure and diagnosis codes for medical necessity\\n\\tDetermine whether claimant&rsquo;s plan covers the claim submitted and how much money, if any, should be paid\\n\\tAuthorize 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&rsquo;s clients)\\n\\tReview Workflow Manager daily to document and release pended claims&nbsp;\\n\\tReview Pended Claim Reports and close out pended claims for which no response has been received\\n\\tReview Suspended Claim Reports and follow up on open issues\\n\\tProcess Adjustment Claims when necessary, due to corrected claims as well as applying refunds in the QL system\\n\\tAssist and support other claims adjusters as needed and when requested\\n\\tAttend continuing education classes as required, including but not limited to HIPAA training\\n\\tOther duties as assigned\\n\\n\\n&nbsp;\\n\\nEDUCATION\\n\\n\\n\\tHigh School Diploma required, and College Preferred.\\n\\tContinuing education in all areas affecting group health and welfare plans is required.\\n\\n\\n&nbsp;\\n\\nEXPERIENCE AND SKILLS&nbsp;\\n\\n\\n\\tApplicants must have a minimum of five (5) years of medical claims analysis and adjudication experience (including dental and vision claims analysis)&nbsp;\\n\\tApplicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-10 coding terminology&nbsp;\\n\\tApplicants must demonstrate the desire to assist with exceeding all established goals\\n\\tPrior experience in Adjustment Processing is preferred but not required\\n\\n\\n&nbsp;\\n\\nCOMPETENCIES\\n\\n\\n\\tAccountability\\n\\tAnalytical Thinking\\n\\tCollaboration\\n\\tCommunication\\n\\tCustomer Focus\\n\\tFunctional Expertise\\n\\tInitiative\\n\\n\\n&nbsp;\\n\\nPHYSICAL DEMANDS\\n\\n\\n\\tThis is a standard desk role that requires extended periods of sitting and computer work\\n\\n\\n&nbsp;\\n\\nWORK ENVIRONMENT&nbsp;\\n\\n\\n\\tRemote\\n\\n\\n&nbsp;\\n\\nHere at Allied, we believe that great talent can thrive from anywhere. 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