at Health Care Service Corporation in Chicago, Illinois, United States
Job Description
Welcome to a team of caring and passionate people who work each day to meet the needs of our members and clients. At Luminare Health (a subsidiary of Health Care Service Corporation), you will be part of an organization committed to offering custom services to self-funded health benefits plans that manage costs - without compromising benefits - by offering innovative solutions, flexibility, transparency and customer support. This is an exciting time to join our team and enhance our culture that emphasizes caring, diversity and inclusion, mutual respect, collaboration and service to our communities.
Job SummaryUnder minimal supervision, the Claims Specialist is responsible for reviewing and investigating high dollar claims and claim appeals to determine if the incurred services were billed, adjudicated, and reimbursed in accordance with the terms and conditions of the applicable client's summary plan document to understand benefit coverage levels. Consistently researches and analyzes claims for accuracy and recommends immediate and long term solutions for improvement.
LIFE & DISABILITY - CLAIMS SPECIALIST
Secure and analyze claim information to make and approve decisions and payments on life and/or disability claims. Develop, apply and approve appropriate claim and management strategies to ensure prompt and accurate payment and liability management of life and/or disability claims, including complex, high liability or more problematic claims. Provide responsive and caring customer service to internal and external customers; participate actively and effectively in team/department projects and issues. All aspects of claim management completed under minimal supervision of the senior manager.
Required Job Qualifications:
4 years medical claims processing experience.
Must possess and apply a comprehensive knowledge of specialized medical claims processing, an understanding of code review edits as well as fraud and abuse patterns.
Ability to provide excellent communication in verbal and written form. Excellent interpersonal skills.
Performance and audit scores of 99% payment, 97% financial and 97% accuracy (or better).
Familiarity with various PPO reimbursement methodologies.
Possess a basic knowledge/understanding of stop loss coverage.
Computer proficiency in Microsoft Office programs.
Exceptional organization skills.
Extremely detail oriented.
Ability to work effectively with team members, employees, providers, and clients.
Ability to work in a fast-paced, customer service driven environment.
Supervisor work ethic.
Preferred Job Qualifications:
Employment with HB as a Medical Claims Analyst and then Sr. Claims Analyst preferred.
LIFE & DISABILITY - CLAIMS SPECIALIST
Required Job Qualifications:
Strong disability and/or life claim knowledge - understanding of all aspects of claims examining; solid investigation, analytical and organizational skills, and attention to detail or the equivalent combination of relevant experience.
Minimum fives years insurance claim experience with an understanding of medical terminology.
Must have strong math and decision-making skills, the ability to keep accurate, detailed records and the ability to thoroughly document claim information.
Possess creative problem solving and conflict resolution skills.
Ability to organize workflow and accept additional tasks and projects. Developing an understanding of the operations of other company departments and their relationship to team responsibilities is essential.
Strong time management skills to prioritize workload, manage numerous tasks, and provide support to other team members.
Must be a self-starter, as defined by their ability to take responsibility for prioritizing, managing and following up on numerous tasks.
Capable of making decisions in the absence of specific directions, independently or with minimal supervision.
Must have excellent verbal and written communication skills with a passion for helping others.
Capable of making informed decisions, handle pressure well, interact effectively with other departments and meet prescribed deadlines.
Ability to foster a positive team environment.
Possess adaptability to new systems, policies and environments; responsive to change and improvement methodologies.
Effective in the use of personal computers and related software. Proficiency in working with... For full info follow application link.
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
