Claims Specialist (Healthcare)

Core Functions:

In this fully remote position, the claims specialist is responsible for overseeing the entire claims process for the department ensuring accuracy, quality, and timeliness for all healthcare claims. The claims specialist will serve as the SME on claims and will train, resolve problems, and improve processes to drive higher performance of the team. This person will also provide accurate and timely reporting on claims status to all parties involved.

Essential Duties & Responsibilities:
 

• A core responsibility is to maintain client communication system with provider network and work closely with global staff to ensure results loaded with client systems.
• Conduct training for the global team on claims processing and systems (both internal and client).
• Manage complex issues/claims; serve as a point of escalation and resolution for international team.
• Complete file loads to client systems.
• Identify and implement process improvements to ensure accurate, clean client file submissions and increase efficiency of client response files.
• Complete monthly reconciliation of claims and payments.
• Monitor and report on client response files and claims process ensuring all parties are kept up to date on program status.
• Up to 5% travel annually

Required Qualifications

• 5+ years’ work experience in healthcare claims processing with in-depth experience with payor systems and their processes.
• Demonstrated results in a work environment where identifying, researching, and solving problems was required to be successful in the position.
• Knowledge of a variety of healthcare payment methodologies.

• SME on how all types of healthcare claims pay with the ability to identify where things could/did go wrong and solve the issues.

• Strong knowledge of healthcare data and processes – knows the acronyms and what they mean to the overall process and has worked through solving problems related to that data.

Preferred Qualifications

• Bachelor’s Degree in Healthcare Administration or related field of study.

• Diverse background knowledge of healthcare claims inpatient, outpatient and professional experience preferred.

Professional Qualifications

• Strong communication skills (verbal and written) with ability to communicate with all levels of employees and international staff.

• Strong analytic and problem-solving skills.
• Excellent research skills.
• Knowledge of a variety of healthcare payment methodologies.
• Able to multitask and keep track of details.

Working Conditions Physical & Mental Demands:

• Sitting for extended periods of time while working on a computer/laptop.

• Visual Requirements

• Dexterity Requirements include regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); ability to use various writing tools (note taking); ability to operate a computer keyboard / mouse and other office equipment required for this position.
• Hearing and Speaking Requirements include the ability to hear normal speech, hear and talk to exchange information in person and over the cellphone / telephone sometimes using earphone headsets.
• Flexibility to remotely work varied shifts and hours to meet business needs.
• Communicating verbally and in written English language to meet business needs.
• Managing difficult conversations with determinations of requests and notifications to clients / providers and members of your Team.

Acknowledgement:

Contents of the job description is not restricted from change. EXL Health Management retains the right to assign, re-assign duties and responsibilities at any time to meet the business obligations and expectations.

What We Offer

EXL Health offers an exciting, fast paced, and innovative environment, which brings together a group of sharp and entrepreneurial professionals who are eager to influence business decisions.

From your very first day, you get an opportunity to work closely with experienced, world-class Healthcare consultants.

You can expect to learn about many aspects of businesses that our clients engage in. You will also learn effective teamwork and time management skills - key aspects for personal and professional growth.

We provide guidance/ coaching to every employee through our mentoring program where in every junior level employee is assigned a senior level professional as advisors.

Sky is the limit for our team members. The unique experiences gathered at EXL Health sets the stage for further growth and development in our company and beyond.