Claims Specialist II

The Claim Specialist II position plays a pivotal role in the success of our organization, by adjudicating all reimbursement requests for our participants in a timely and accurate manner. Working with high volumes and strict turnaround times, the Claim Specialist II understands the intricacies of the products we offer, as well as the IRS regulations that govern our abilities to pay or deny a claim. The position is responsible for adhering to HIPAA guidelines and is responsible for performing complex claim adjudication duties related to Section 125, 129, 132, 105(h) plans, Lifestyle etc. to maximize quality, quantity, and total customer/client satisfaction.

Effective performance of all duties and responsibilities of the position will ensure accurate and timely completion of required tasks and compliance with required timelines.

Key Responsibilities

• Process claims in a timely manner (within 1-2 days) in accordance with P&A’s policies, procedures and plan documents.
• Coordinates responses for routine phone inquiries, written correspondence, and internal questions related to claim processing inquires.
• Draft and send manual adverse determination letters to inform participants of the need for additional information, or to afford them the right to appeal, per plan rules.
• Adjudicate card transactions that fail auto-review & make the determination if additional information is required to approve the transaction.
• Review and process requests for claim or balance modifications.
• Review letters of medical necessity and make approval/denial determination as per regulatory requirements.
• Review HIPAA authorizations and enter data into software systems in accordance with departmental policies and procedures.
• Accurately enter banking information into software platforms to facilitate direct deposit transactions in accordance with departmental policies and procedures.
• Monitor and take appropriate action on ACH reversal requests.
• Review and process claims flagged as potential duplicates and ensuring they are processed correctly.
• Review claims queues regularly processing in order of priority to ensure timely claim turnaround in accordance with departmental policies and procedures.
• Investigates and responds to all claim inquiries promptly and professionally.
• Make recommendations to increase the efficiency and accuracy of claims processing and training practices.

Other Functions

• Champion P&A Group values and policies.
• Maintain data protection, privacy, security and maintain HIPAA compliance for participants and clients.
• Completes any additional assignments as requested by the executive/management team members.
• Provide mentoring/support of team and/or identify/deliver training for team.
• Ad-Hoc reporting, analysis and presentations as required.