Claims Specialist

COMPANY OVERVIEW: HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences. We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously. We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish. APPLICATION INSTRUCTIONS: We're moving quickly to fill these roles, so we appreciate your attention to detail during the application process! To help ensure a smooth and efficient review process, please complete all sections of the application form--incomplete applications may not be considered. PURPOSE AND SCOPE: The Claims Specialist serves Medicare insurance customers by determining insurance coverage; examining and resolving Medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance. PRINCIPAL RESPONSIBILITIES AND DUTIES: Responsible for processing claims in accordance with production, timeliness and quality standards. Participates with other health plan departments in the resolution of claims issues across department lines. Ensures claims are processed in compliance with governmental and accrediting agency regulations. Ensures the delivery of superior customer service by providing timely and accurate claims payment and responding timely to member and provider inquiries and complaints regarding claims processing. Develops strong intradepartmental relationships with other department personnel and/or exempt individual contributors to ensure clear communication and prompt resolution to issues. Follows departmental policies and procedures regarding claims adjudication. Ensures that potential fraudulent claims practices are identified and reported to the appropriate compliance department. Follows all HIPAA compliance guidelines to ensure protection of member protected health information. Responsible for driving the HealthAxis culture through values and customer service standards. Accountable for outstanding customer service to all external and internal contacts. Develops and maintains positive relationships through effective and timely communication. Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner. EDUCATION, EXPERIENCE AND REQUIRED SKILLS: Understanding of hospital and/or physicians’ contracts to determine payable benefits and knowledge of pricing DRG, APC and per diem for all Medical claim products. Excellent oral and written communication skills including good grammar, voice and diction. Able to read and interpret documents and calculate figures and amounts. Proficient in MS Office with basic computer and keyboarding skills. Excellent customer service skills (friendly, courteous and helpful). EDUCATION: High school diploma or general education degree (GED) required. Minimum two years’ experience in managed care claims processing environment required. Experience with the internal configuration of claim processing systems and the links between contracts, utilization management and claims processing within these systems required. An equivalent combination of education, training, and experience.