Claims Specialist (REMOTE)

<strong>Working at Advantasure is more than a job &mdash; you&rsquo;re part of a team that is becoming the country&rsquo;s leading healthcare solutions provider.<br /></strong><br /><strong>A career at Advantasure means you&rsquo;ll be part of one of the most dynamic, diversified and innovative healthcare companies in the nation. You&rsquo;ll be helping our clients make their members healthier &mdash; and our communities a better place to call home.</strong>

United States, USA


<p class="p1"><strong>At Advantasure, we partner with healthcare clients to simplify their operations and accelerate their business success. Powered by our broad expertise and a comprehensive suite of product and service solutions, we help health plans effectively navigate the complexity of healthcare.</strong></p>

keywords: job description,analysis,performance,claims,other duties,education,experience,communication,skills


Competitive Compensation and Benefits Package

Overview: <br />The Claims Specialist is<strong>&nbsp;</strong>responsible for the coordination, development, and implementation of programs and strategies to improve service to customers in the area of claims processing.<br /><br /> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards.</p>
Responsibilities: <br /> <ul> <li>Conducts and&nbsp;coordinates investigations&nbsp;on all assigned claims to provide accurate facts for disposition, including on-site and desk investigation analysis.</li> <li>Analyzes intelligence information and makes determination for further investigation claims utilizing available resources.</li> <li>Follows established policies and procedures for conducting causation evaluations.</li> <li>Provides accurate and timely information to all internal and external stakeholders to address claim status and other inquiries, such as questions on subrogation recovery, reserve adequacy, and underwriting risks.</li> <li>Consistently monitors workflows to maximize efficiency.&nbsp;</li> <li>Maintains an acceptable level of service and customer satisfaction and retention.</li> <li>Analyzes trends and completes comprehensive and detailed reports.</li> <li>Assists with evaluation of training needs and designs and develops training modules, materials, and evaluations related to causation and subrogation for internal and external customers as needed.</li> <li>Applies up-to-date technical knowledge of investigative core functions.</li> <li>Delivers presentations as needed.</li> <li>Updates metric tracking documents monthly.</li> <li>Analyzes and interprets CMS changes and their potential impacts on claims processing.</li> <li>Develops system testing, scenarios, procedures, and controls and provides recommendations for ongoing improvement.</li> <li>Works with configuration on testing and system adjudication logic.</li> </ul>
Requirements: <br /> <p><strong>EDUCATION: &nbsp;</strong></p> <ul> <li>Bachelor&rsquo;s degree in a related field.&nbsp;</li> <li>Relevant combination of education and experience may be considered in lieu of degree. &nbsp;</li> <li>Continuous learning, as defined by the Company&rsquo;s learning philosophy, is required.&nbsp;</li> <li>Certification or progress toward certification is highly preferred and encouraged.</li> </ul> <p>&nbsp;</p> <p><strong>EXPERIENCE:</strong></p> <ul> <li>Five years experience of progressive responsibility in health insurance claims processing with demonstrated technical knowledge that provides the necessary knowledge, skills, and abilities required.&nbsp;</li> </ul> <p>&nbsp;</p> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Technical knowledge of insurance administration, claims management, or relevant insurance expertise.</li> <li>Knowledge of insurance claims processing rules and payment methodologies.</li> <li>Strong interpersonal and superior communication skills, including verbal and professional writing.</li> <li>Strong report preparation and presentation capability.</li> <li>Strong expertise in word processing and spreadsheets with knowledge of Microsoft applications.</li> <li>Ability to effectively exchange information clearly and concisely, present ideas, and respond to questions as appropriate, both in oral and written communications.</li> <li>Up-to-date technical knowledge to investigative core system functions.</li> <li>Ability to quickly make decisions and comprehend the consequences of various problem situations and take appropriate actions, and/or refer problems for necessary decision making.</li> <li>Ability to organize and prioritize multiple assignments.</li> <li>Ability to work within tight timelines when necessary.</li> <li>Ability to work with minimal supervision.</li> <li>Ability to identify workflow options to create and improve claims processing.</li> <li>Ability to continually exercise discretion and independent judgment in matters of significance.</li> <li>Ability to lead claim testing and communicate findings and resolutions.</li> <li>Knowledge of Ika systems.</li> </ul>