Medicare Advantage Claims Processing

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    "datePosted": "2025-08-28",
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    "description": "<p><span style=\"font-weight: bold\"><span style=\"font-size: 15px\"><span style=\"font-size: 18px; font-weight: bold\">We welcome applications for our Claims Specialist positions at any time. If we do not have any current openings, we will keep applications on file and review them regularly. If your background is a strong match, we’ll reach out to set up an interview.</span></span></span></p>\n<p><span style=\"font-weight: bold\"><br></span><br></p>\n<p><span style=\"font-weight: bold\"><span style=\"font-size: 15px\">Position Title:</span></span><span style=\"font-size: 15px\">  Claims / Encounter Specialist *Remote*</span></p>\n<p><br></p>\n<p><span style=\"font-weight: bold\"><span style=\"font-size: 15px\">Reports To:</span></span><span style=\"font-size: 15px\">   BPaaS Operations Manager/Director</span></p>\n<p><br></p>\n<p><br></p>\n<p><span style=\"font-weight: bold\"><span style=\"font-size: 15px\">Position Summary:</span></span><span style=\"font-size: 15px\">   The Claims / Encounter Specialist will be required to perform reviews of pended claims of all types and specialties, apply business rules and finalize claims in accordance with regulatory and client expectations.  Additionally, the specialist will review adjustment requests and determine whether to uphold the original decision or perform an adjustment of the claim to correct outcomes.   This role will also be required to assist with review and preparation of claims data for submission of encounters.  The specialist must have excellent analytical skills, along with keen attention to detail and good written and oral communication abilities. </span></p>\n<p><br></p>\n<p><br></p>\n<p><span style=\"font-weight: bold\"><span style=\"font-size: 15px\">Responsibilities:</span></span></p>\n<ul>\n<li><span style=\"font-size: 15px\">Perform timely and accurate claim adjudication and adjustments</span></li>\n<li><span style=\"font-size: 15px\">Adjudicate specialty claims, including, but not limited to ambulatory surgery, skilled nursing, dental, anesthesia, medical assistance, reprocessed claims, duplicate claims, ambulance, durable medical equipment (DME), or institutional based charges.</span></li>\n<li><span style=\"font-size: 15px\">Prepare encounters for submission and correct rejected encounters</span></li>\n<li><span style=\"font-size: 15px\">Support system inquiries documented from the member and provider call center services</span></li>\n<li><span style=\"font-size: 15px\">Research and review Claims Appeals information to support client inquiries</span></li>\n<li><span style=\"font-size: 15px\">Meet established production and quality standards</span></li>\n<li><span style=\"font-size: 15px\">Identify opportunities to improve efficiency within assigned processes</span></li>\n</ul>\n<p><span style=\"font-size: 15px\"> </span></p>\n<p><span style=\"font-size: 15px\"> </span></p>\n<p><span style=\"font-weight: bold\"><span style=\"font-size: 15px\">Minimum Requirements</span></span></p>\n<p><br></p>\n<p><span style=\"font-size: 15px\">Industry Experience</span></p>\n<ul>\n<li><span style=\"font-size: 15px\">1-3 years in healthcare industry experience working in the payer segment in Medicare Advantage, Managed Medicaid, or working with an industry competitor. </span></li>\n<li>Experience in BPaaS environment is a plus.</li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 15px\">Skills &amp; Knowledge</span></p>\n<ul>\n<li><span style=\"font-size: 15px\">Candidate should have experience working in a production environment and the ability to meet performance standards. </span><span style=\"font-size: 15px\"> Attention to detail and the ability to apply documented procedures to achieve desired outcomes are also required.  </span><span style=\"font-size: 15px\">MS Word and MS Excel, good interpersonal skills, written and oral communication abilities a must.  </span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 15px\">Years of Experience</span></p>\n<ul>\n<li><span style=\"font-size: 15px\">1-3 years</span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 15px\">Education</span></p>\n<ul>\n<li><span style=\"font-size: 15px\">A High School Diploma is required.</span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-size: 15px\">Compensation and Benefits</span><br></p>\n<ul>\n<li>Competitive hourly rate commensurate with experience</li>\n<li>100% remote work culture</li>\n<li>Health, dental &amp; vision insurance</li>\n<li>Vacation and holiday pay</li>\n<li>Traditional and ROTH 401k with company match</li>\n<li>Company paid life insurance, AD&amp;D, and long-term disability coverage</li>\n<li>HSA and FSA accounts</li>\n<li>Tuition Reimbursement</li>\n<li>Parental Leave<br></li>\n</ul>\n<p><br></p>\n<p><br></p>\n<p><span style=\"font-family: 'Calibri',sans-serif; font-size: 10.0pt\">Compliance:</span><span style=\"font-family: 'Calibri',sans-serif; font-size: 10.0pt\"> All employees shall comply with company policies, including those related to security and privacy, as well as with applicable laws and regulations such as the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health (HITECH) Act, and other relevant federal and state regulations.</span></p>\n<p><span style=\"font-family: 'Calibri',sans-serif; font-size: 10.0pt\"> </span></p>\n<p><span style=\"font-family: 'Calibri',sans-serif; font-size: 10.0pt\">Data Protection:</span><span style=\"font-family: 'Calibri',sans-serif; font-size: 10.0pt\"> Employees are responsible for safeguarding protected health information (PHI) and personally identifiable information (PII) in accordance with company policies and HIPAA regulations. This includes ensuring that all data is accessed, processed, stored, and transmitted securely.<br></span></p>\n<p><span style=\"font-size: 15px\"><br></span></p>",
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