Claims Specialist - Bronx, NY

Claims Specialist

Bronx, NY

Schedule: M-F, 8:30am to 5:30pm

Work Location: Hybrid

Assignment Length: Undetermined, potential for Direct Hire

FlexStaff is seeking a Claims Specialist for our client, a non-profit healthcare organization providing home and community-based healthcare and services for the elderly. This role is responsible for supporting department operations related to provider communication, pending claim review, reporting, auditing, and oversight activities.

Responsibilities:

• Responsible for reviewing claims processed by the outside vendor, including resolving provider appeals/disputes.

• Compiles claim reports

• Investigates suspense conditions

• Communicates and follows up with a variety of internal and external sources

• Attends JOC meetings with providers as appropriate

• Ensures that refund checks are logged and processed

• Generates routine daily, monthly and quarterly reports

• Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor

• Analyzes patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditions

• Other related duties as assigned by the supervisor

Qualifications:

• Bachelor's degree

• Certified Professional Coder, a plus

• Eight or more years of insurance experience within a healthcare setting, preferred

• Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system

• Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS

• Knowledge of MLTC/ Medicaid/Medicaid benefit, Member (Subscriber) enrollment & billing, Utilization Authorizations, Provider Contracting

Additional Salary Detail

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).