Claims Specialist 5254

Tier4 Group; Baton Rouge (LA); On-site; USD 42,000 - 64,000; Full time

Job summary

Tier4 Group in Baton Rouge seeks a Claims Specialist II to join our healthcare operations team. The role focuses on accurate medical claims processing, benefits coordination, and strong COB knowledge to determine primary vs secondary payers.

You will investigate discrepancies, recover overpayments, and collaborate with members, providers, and internal teams to maintain high-quality service and financial accuracy.

Qualifications

• Minimum two years of medical claims processing experience.
• Strong analytical and investigative skills to resolve complex claims.
• Excellent written and verbal communication abilities.
• Ability to prioritize tasks in a fast-paced environment.

Responsibilities

• Review and process medical claims with accuracy and attention to detail.
• Research and resolve claim edits, denials, and payment discrepancies.
• Determine primary vs. secondary coverage when multiple plans exist.
• Apply COB rules, including subscriber status and dates.
• Update claims and coverage records for accurate adjudication.
• Investigate prior processed claims and adjust benefits as needed.
• Identify and recover overpayments through refunds and reprocessing.
• Communicate with members, providers, and carriers to resolve issues.
• Assist with quality audits and process improvements.

Skills

Medical claims processing

Analytical skills

Investigative skills

Communication skills

Multitasking

MS Office proficiency

Education

High School Diploma or equivalent

Tools

Claims processing systems

Microsoft Office

Job description

We're looking for a Claims Specialist II to join a growing healthcare operations team. This is an excellent opportunity for a claims professional who thrives on problem-solving, enjoys working with data and documentation, and takes pride in delivering accurate results.

The ideal candidate will have experience in medical claims processing and a strong understanding of Coordination of Benefits (COB). If you've worked with multiple insurance coverages, determined primary versus secondary payers, resolved claim discrepancies, and recovered overpayments, we'd love to hear from you.

What You'll Be Doing

As a Claims Specialist II, you'll play a critical role in ensuring claims are processed accurately, benefits are coordinated correctly, and members, providers, and internal stakeholders receive exceptional service.

Your responsibilities will include:

• Reviewing and processing medical claims with accuracy and attention to detail.
• Researching and resolving claim edits, denials, and payment discrepancies.
• Determining primary and secondary insurance coverage when members have multiple health plans.
• Applying Coordination of Benefits (COB) rules, including subscriber status, effective dates, plan types, and Medicare coordination guidelines.
• Updating claims and coverage records to ensure accurate claim adjudication.
• Investigating previously processed claims and making necessary benefit adjustments.
• Identifying and recovering overpayments through refunds, reprocessing, and recovery efforts.
• Communicating with members, providers, healthcare organizations, and insurance carriers to verify coverage and resolve claim issues.
• Reviewing quality audits and implementing corrections to maintain compliance and processing accuracy.
• Supporting special projects, process improvements, system updates, and departmental initiatives as needed.

Required Qualifications

• High School Diploma or equivalent.
• Minimum of two (2) years of medical claims processing experience.
• Strong analytical and investigative skills with the ability to resolve complex claims issues.
• Excellent written and verbal communication skills.
• Ability to prioritize and manage multiple tasks in a fast-paced environment.
• Proficiency with claims processing systems and Microsoft Office applications.

Preferred Experience

• Coordination of Benefits (COB) processing experience.
• Experience determining primary versus secondary insurance coverage.
• Knowledge of Medicare coordination and payer primacy guidelines.
• Experience researching claim discrepancies and resolving overpayments.
• Healthcare insurance, payer, or benefits administration experience.

Why This Opportunity?

This role offers the chance to work on challenging claims scenarios that require critical thinking, investigation, and problem-solving. You'll be part of a collaborative team focused on delivering quality service, maintaining financial accuracy, and supporting positive outcomes for members and providers.