Insurance Claims Specialist

Assist clients with the claim, appeal, inquiry, and/or complaint process. Conducting research and make determinations on Claims and provide research to clients for Appeals. Work on multiple clients while researching, analysing, and making a determination on each participant issue using plan documents and guidelines. Draft and mail an individualized response letter to the plan participant.

RESPONSIBILITIES INCLUDE:

- Process claims, appeals, inquiries, and complaints for a group of clients.
- Complete their assigned claims and appeals within ERISA timeframes.
- Research claims and appeals using a number of resources such as: TBA, CPro, Imaging, Lotus Notes databases, client plan documents, and client guidelines.
- Interact with the Client, Benefit Center, Plan Management, Advocacy, Connections, Health Plans, and Providers.
- Handle incoming calls related to Concurrent and Urgent Care claims and appeals on a rotational schedule.
- Maintain high levels of confidentiality.
- Work to achieve certification, if not already certified.
- Shows initiative and positive attitude.
- Developing Subject Matter Expertise.

SKILLS:

- College degree preferred but not required
- One or more years experience in handling and resolving complex client escalation issues
- Experience on a multi-client/multi-service team is a plus but not required
- Some legal background a plus but not required
- Strong working knowledge of Workstation functionality
- Solid verbal and written communication skills, including solid business writing skills required
- Multitasking and time management
- Problem solving, research skills, attention to details
- Windows XP, Lotus Notes, Word, Excel, PowerPoint
- Legal Requirements, Health Plans and Connections
- HIPPA, ERISA, COBRA, Section 125, and DOL regulations, and several types of benefits
- Ability to work first shift and third shift several times a month
- Ability to work effectively in a dynamic environment
- Must be able to work independently as well as collaboratively in a team environment