Claims Specialist

Talentify; New York (NY); Hybrid; USD 60,000 - 80,000; Full time

Job summary

A leading company is immediately hiring a Claims Specialist to support department operations related to claims processing. This role involves reviewing, investigating claims, and ensuring compliance with applicable guidelines. Candidates should possess strong skills in claims analysis and medical billing, ideally with experience in a healthcare setting.

Benefits

Medical, dental & vision

401(k) Retirement Plan

Life Insurance (Voluntary Life & AD&D)

Short and long-term disability

Health Spending Account (HSA)

Transportation benefits

Employee Assistance Program

Time Off/Leave (PTO, Vacation or Sick Leave)

Qualifications

• Experience in claims processing and medical billing.
• Knowledge of Medicaid and benefits.
• Familiarity with medical coding and terminologies.

Responsibilities

• Review and investigate claims for adjudication.
• Compile adjustment reports and communicate with providers.
• Analyze medical information to identify benefits coordination.

Skills

Claims processing and analysis

Medical billing and claims handling

Proficiency in Microsoft Office Suite

Knowledge of Managed Long Term Care (MLTC)

Understanding of Utilization Authorizations

Familiarity with CPTs, ICD-9/ICD-10

Education

Certified Professional Coder certification

Experience in healthcare or managed care setting

Tools

Claims processing systems

Job description

Immediately Hiring a Claims Specialist!

The Claims Specialist will support department operations related to provider communication, pended claim review, reporting, auditing, and oversight activities to ensure compliance with all applicable State, Federal, and contractual guidelines.

Job Responsibilities:

• Review and investigate claims to be adjudicated by the Third Party Administrator (TPA), including the application of contractual provisions in accordance with provider contracts and authorizations.
• Compile claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner.
• Investigate suspense conditions to determine if system or procedural changes would enhance claim workflow.
• Communicate and follow up with a variety of internal and external sources, including providers, members, attorneys, regulatory agencies, and other carriers on any claim-related matters.
• Analyze patient and medical information to identify Coordination of Benefits (COB), Worker's Compensation, No-Fault, and Subrogation conditions.

Skills & Qualifications:

• Claims processing and analysis.
• Medical billing and claims handling.
• Proficiency in Microsoft Office Suite.
• Experience with claims processing systems or comparable database software.
• Certified Professional Coder certification is a plus.
• Experience within a healthcare or managed care setting preferred.
• Knowledge of Managed Long Term Care (MLTC), Medicaid, and Medicaid benefits.
• Understanding of Utilization Authorizations.
• Familiarity with CPTs, ICD-9/ICD-10, HCPC, DRG, Revenue, and RBRVS.

Pay and Benefits

The pay range for this position is $20.00 - $25.00/hr.

Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a hybrid position in Bronx,NY.

Application Deadline

This position is anticipated to close on Jun 27, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [e-mail] for other accommodation options.