Claims Specialist II

Job Summary

Processes Wellness, Accident and Hospital Indemnity insurance claims and determines the nature and validity of claims by reviewing policy status, patient eligibility, and supporting medical documentation; submits claims for payment or further investigation; provides prompt customer service for inquiries from policy holders, providers, or agents regarding claim status

Principal Duties & Responsibilities

• Under general supervision and in accordance with established policies and procedures, reviews and processes insurance claims (Wellness, Accident, and Hospital Indemnity)based on information submitted by policy holders; determines the nature and validity of claims by reviewing policy status, patient eligibility, and supporting medical and other documentation

• Keys claims data while interpreting coding and medical terminology in relation to diagnoses and procedures; uses multiple core administration databases, systems and subsystems to process and transmit claims for payment or further investigation

• Communicates customer inquiries to management to provide information for improvement of overall service levels; manages claim risk exposure; reviews and assesses existing work processes and recommends process improvements or enhancements

• Reviews medical chart notes, provider bills, procedure codes, diagnosis codes, charges and medical records in order to determine validity of accident claim; collects needed information, researches diagnoses, procedures, ad eligibility for payment under accident policy

• Provides prompt customer service to policy holders, providers and other internal company entities regarding claims; documents phone calls in the system and follows-up on issues if needed; contacts insured or other appropriate persons to verify the accuracy and completeness of information on claims forms and related documents, responds to inquiries from policy holders, providers, agents regarding claim status and policy provisions

• Provides back-up coverage for other teams as required, maintains databases and prepares and extracts information using software systems; performs various clerical duties as assigned, such as filing, photocopying, typing, maintaining databases and preparing and extracting information using software systems

• As assigned, supports EXL with non-routine Claims, researching missing or inaccurate information; provides other administrative support to EXL as needed

• As assigned, assists with Electronic Fund Transfer setup/maintenance and keeps records of all EFT entries; audits accuracy of EXL production

• Assists with successful transition of new employees from training to the work environment; addresses situations escalated from less experienced specialists and escalates as necessary to lead specialist

• Performs other related duties as required

Education & Experience Required

• High School Diploma or Equivalent
• 2 years of job-related experience
• Experience and proficiency using Microsoft Office Suite software

Or an equivalent combination of education and experience

Education & Experience Preferred

• ICD/CPT coding knowledge
• Experience with medical terminology and human anatomy

Job Knowledge & Skills

• Knowledge of principles and processes for providing customer and personal services; this includes needs assessment, meeting quality standards for services, and evaluation of customer satisfaction

• Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, and other office procedures and terminology

• Skill in giving full attention to what other people are saying; taking time to understand the points being made; asking questions as appropriate

• Skill in understanding the implications of new information for both current and future problem solving and decision-making

• Skill in using mathematics to solve problems

• Skill in selecting and using training/instructional methods and procedures when learning new policies, procedures, concepts or products
• Skill in managing one’s own time and the time of others and actively looking for ways to help people

• Positions requiring the use of bilingual skills: Fluency in Spanish with the ability to translate documents

Competencies

• Acting with Integrity - Clearly states goals and beliefs; lets people know his/her true intentions; does what he she said they would do; follows through on commitments
• Communicating Effectively - Expresses ideas and information in a clear and concise manner; tailors message to fit the interests and needs of the audience; delivers information in a manner that is interesting and compelling to the listener
• Pursuing Self-Development - Demonstrates ambition and desire to move forward in his/her career; engages others in discussions about career development; seeks feedback on ways to increase his/her performance; takes advantage of opportunities to build new skills and capabilities
• Serving Customers - Builds strong relationships with customers; stays aware of customer needs, concerns and satisfaction; responds promptly to customer questions and requests; effectively manages
• Supporting Change - Enthusiastically participates in new change initiatives and programs; focuses on reasons why changes will work and how they will be beneficial
• Supporting Organizational Goals - Actively supports organizational goals and values; demonstrates enthusiasm toward the company's goals and mission; aligns actions around organizational goals
• Working with Diverse Populations - Shows respect for the beliefs and traditions of others; encourages and promotes practices that support cultural diversity; discourages behaviors or practices that may be perceived as unfair, biased, or critical toward people with certain backgrounds