Claims Specialist II

Trillium Health Resources; Clayton (NC); Remote; USD 43,000 - 62,000; Full time

Benefits offered by this job

Health insurance

Remote work options

PTO & holidays

401k matching

Job summary

Trillium Health Resources is seeking a Claims Specialist II to analyze, audit, and finalize adjudication results for NC Medicaid claims, using CMS guidelines and internal policies. You will assist providers via phone or email and coordinate with internal and external stakeholders for timely resolutions.

The role emphasizes data-driven decision making, claims education, and support across the NC catchment. Remote work within NC is available with standard hours and benefits.

Qualifications

• High School Diploma or GED with 2 years in claims processing or related field.
• Valid driver's license and NC residency.
• Eligible to work in the United States without sponsorship.

Responsibilities

• Analyze and audit claims adjudication results to determine accuracy per NC Medicaid guidelines.
• Audit claim attachments/medical documentation to adjudicate claims.
• Audit and act on claims delayed for adjudication due to errors.
• Identify adjudication errors and provider billing issues.
• Review trainings and CMS guidelines to ensure compliance.
• Provide training and technical assistance to providers on submission guidelines.
• Report system issues to supervisor based on data analysis.

Skills

Data analysis

Auditing

Claims processing

Provider support

Policy knowledge

Education

High School Diploma or GED

Associates degree (preferred)

Tools

Billing software

Job description

Pay Plan Title: Claims Specialist II

Working Title: Claims Specialist II

FLSA Status: Non-Exempt

Posting Salary Range: $42,765 - $61,546

Office Location: Remote within North Carolina

POSTING DETAILS:

Make an Impact

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.

Why Work for Us?

Trillium believes that empowering others begins with supporting our team. We offer our employees:

• A collaborative, mission-driven work environment
• Competitive benefits and work-from-home options for most positions
• Opportunities for professional growth in a diverse inclusive culture

Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.

What We’re Looking For

Trillium Health Resources has a career opening for a Claims Specialist II to join our team! The Claims Specialist II performs data analysis, auditing and finalizes adjudication results for claims designated for pre-payment review and post payment review of claim adjudication results through research and knowledge of billing guidelines and policies established by CMS, and NC Medicaid as well as Trillium policies and procedures. This position is also responsible for assisting providers by phone or email with claims processing questions as well as communicating with internal and external stakeholders to facilitate efficient claims resolution.

On a typical day, you might:

• Analyze and audit claims adjudication results to determine if claims were accurately submitted and processed according to NC Medicaid guidelines.
• Analyze and audit claim attachments/medical documentation necessary to appropriately adjudicate a claim.
• Analyze, audit and take appropriate actions for claims delayed for adjudication due to rejection errors.
• Identify adjudication errors, provider billing errors, and the need for technical assistance.
• Ensure the claims system and manual processes are incorporating required actions by reviewing and applying information from departmental trainings, published coverage policies and other NCDHHS documents.
• Provide training, education and technical assistance to provider agencies based on analysis or audit findings related to basic claim submission guidelines, denial management, system use and updates.
• Recognize and report suspected system issues or concerns to immediate supervisor for follow-up based on data analysis.

Employee Benefits:

Trillium knows that work/life balance is essential. That's why we offer:

• Typical working hours: 8:30 am - 5:00 pm; flexible work schedules with some roles with management approval.
• Work-from-home options available for most positions
• Health Insurance with no premium for employee coverage
• Flexible Spending Accounts
• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year
• NC Local Government Retirement Pension (defined-benefit plan)
• 401k with 5% employer match and immediate vesting
• Public Service Loan Forgiveness (PSLF) qualifying employer
• Quarterly stipend for remote work supplies

Qualifications

Required:

• High School Diploma or GED and two (2) years of experience in claims processing, billing, or medical coding; OR
• Equivalent combination of education and experience.
• Must have a valid driver's license
• Must reside within North Carolina
• Must be able to travel within catchment as required.
• Must be legally authorized to work in the United States without requiring sponsorship for employment now or in the future (ex: OPT F-1, J-1).

Preferred:

• Associate’s degree in Healthcare Administration, Business, or a Human Services field (such as Psychology, Social Work, etc.)

• Hospital claims experience and knowledge
• Experience in the areas of physical health claims processing or medical coding
• Experience working with Managed Care billing software
• Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS) or similar certification preferred.

Deadline for Application:

Open until filled

Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.

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