Claims Specialist

ProviDRs Care; Town of Texas (WI); On-site; USD 42,000 - 58,000; Full time

Job summary

ProviDRs Care is seeking a Claims Specialist to join our team and support accurate medical claims processing. The role emphasizes compliance, attention to detail, and effective communication with providers and insurers.

You will handle claim forms, verify eligibility, and resolve discrepancies in a fast-paced environment. Ideal candidates bring familiarity with ICD-10/CPT/HCPCS coding, medical billing software, and EHR systems, plus the ability to manage a high volume of claims independently

Qualifications

• High school diploma or equivalent; healthcare field is a plus.
• Experience with medical billing and claim submission processes.
• Knowledge of ICD-10, CPT, HCPCS coding.
• Detail-oriented with accuracy in processing claims.
• Strong communication and interpersonal skills.
• Familiarity with insurance regulations and compliance.
• Ability to handle high-volume claims independently.
• Proficient in MS Office.
• Knowledge of billing software and EHR systems.

Responsibilities

• Process medical insurance claims accurately and efficiently.
• Code medical procedures and diagnoses for claims.
• Verify patient insurance information before processing.
• Review medical records to support claims.
• Follow up on claim status with insurers and providers.
• Investigate and resolve denials; prepare appeals.
• Reconcile billing statements for accuracy.
• Ensure regulatory compliance in claims processing.
• Provide excellent customer service to providers and insurers.

Skills

Attention to detail

Communication

Problem-solving

MS Office

Critical thinking

Interpersonal skills

Independence

Education

High school diploma

Healthcare administration background

Medical billing education

Tools

Billing software

EHR systems

ICD-10/CPT/HCPCS coding

Job description

We are looking for a Claims Specialist to join our team and help our business continue to grow.

Job Description

The Claims Specialist is responsible for accurately processing medical insurance claims, ensuring compliance with industry regulations and guidelines, and resolving any claim-related issues. The Claims Specialist will be a detail-oriented individual who will be responsible for preparing claim forms, verifying information, and corresponding with agents and beneficiaries. Will also handle client inquiries, review policies, determine coverage, calculate claim amounts, and process payments. To be successful as a claim processor, you should have excellent organizational and interpersonal skills. This role requires a strong attention to detail, excellent organizational skills, and a solid understanding of medical billing procedures and insurance policies.

Primary Responsibilities

• Claims Processing: Review and process medical insurance claims accurately and efficiently, ensuring all necessary information is complete and accurate.
• Coding and Documentation: Ensure proper coding of medical procedures and diagnoses using appropriate coding systems (e.g., ICD-10, CPT) to facilitate accurate claims processing.
• Verification: Verify patient insurance information, including eligibility, coverage, and benefits, before processing claims.
• Documentation Review: Review medical records and documentation to ensure that claims are supported by appropriate and valid documentation.
• Claim Status Follow-Up: Communicate with insurance companies and healthcare providers to follow up on the status of claims, resolve claim discrepancies, and provide necessary information for claim processing.
• Denials and Appeals: Investigate and resolve claim denials by identifying discrepancies, addressing coding or billing errors, and preparing appeals when necessary.
• Billing Accuracy: Review and reconcile billing statements to ensure accuracy in charges and payments.
• Regulatory Compliance: Stay updated on relevant industry regulations, insurance policies, and coding guidelines to ensure claims processing follows legal and regulatory requirements.
• Customer Service: Provide excellent customer service to healthcare providers and insurance companies by addressing inquiries and concerns related to claims processing.

Requirements

Skills & Qualifications

• High school diploma or equivalent; healthcare administration, medical billing, or a related field (or equivalent experience) is a plus.
• Proficiency in medical billing software and electronic health record (EHR) systems.
• Knowledge of medical coding systems (ICD-10, CPT, HCPCS) and insurance claim submission processes.
• Strong attention to detail and accuracy in claims processing.
• Excellent communication and interpersonal skills for effective collaboration with team members, healthcare professionals, and insurance representatives.
• Problem-solving skills to resolve claim discrepancies and denials.
• Knowledge of insurance regulations and compliance standards in the healthcare industry.
• Ability to work independently and manage a high volume of claims efficiently.
• Familiarity with medical terminology and healthcare documentation.
• Computer literate and proficient in MS Office.
• Excellent critical thinking and decision-making skills.

Experience

Previous experience in medical billing, claims processing, or a related role is preferred. Familiarity with insurance policies and reimbursement procedures is an asset.