Claims Specialist

Position:
Claims Specialist II (Medical Claims / Coordination of Benefits)

Company:
Not Specified

Compensation:
Up to $19/hour (W2)

Location:
Remote (Louisiana Preferred)

Employment type:
Contract

Short Summary:
We are seeking an experienced Claims Specialist II with medical claims processing experience to support a high-volume health insurance claims operation. This position is responsible for processing and adjusting medical claims, researching claim issues, determining Coordination of Benefits (COB), recovering overpayments, and ensuring claims are processed accurately while maintaining compliance with HIPAA and company policies.

Responsibilities:
- Process medical claims, claims edits, and claims adjustments accurately.
- Research and determine the correct Coordination of Benefits (COB) for members with multiple insurance plans.
- Identify primary and secondary coverage using subscriber status, plan type, Medicare coordination, and effective dates.
- Review and update claims to ensure proper payment and reimbursement.
- Investigate and resolve complex claims issues and discrepancies.
- Process refunds and recover overpayments from providers or members.
- Communicate with providers, members, Medicare, and other insurance carriers regarding claim status and coverage.
- Maintain accurate claims records while ensuring compliance with HIPAA and regulatory requirements.
- Review quality audits and complete corrections within departmental guidelines.
- Support special projects, training initiatives, and departmental process improvements.

Requirement:
- High School Diploma or equivalent
- Minimum 2 years of medical claims processing experience
- Claims processing experience is required
- Coordination of Benefits (COB) experience strongly preferred
- Experience determining primary vs. secondary insurance coverage
- Knowledge of medical claims adjudication and claims edits
- Strong analytical, problem-solving, and investigative skills
- Excellent verbal and written communication skills
- Working knowledge of Microsoft Office and claims processing systems
- Ability to prioritize multiple workstreams in a fast-paced environment

Benefits:
Not Specified