Claims Specialist II

Trillium Health Resources; North Carolina; On-site; USD 43,000 - 62,000; Full time

Benefits offered by this job

Health Insurance with no premium for员工

Flexible Spending Accounts

PTO and paid holidays

NC Local Government Retirement Pension

401k with 5% employer match

Public Service Loan Forgiveness

Remote work stipend

Job summary

Trillium Health Resources is seeking a Claims Specialist II to join our North Carolina team. The role performs data analysis, auditing, and finalizes adjudication results for pre-payment and post-payment review of claim adjudication per CMS, NC Medicaid, and Trillium policies.

The person will assist providers by phone or email with claims processing questions and coordinate with internal and external stakeholders to facilitate efficient resolution.

Qualifications

• Must have 2+ years of experience in claims processing, billing or medical coding.
• Must reside within North Carolina and have a valid driver’s license.
• Travel within catchment as required.

Responsibilities

• Analyze and audit claims adjudication results to ensure NC Medicaid guidelines are followed.
• Analyze and audit claim attachments/medical documentation for adjudication.
• Review and act on delayed adjudication due to rejection errors.
• Identify adjudication errors and provider billing issues needing technical assistance.
• Ensure claims system and processes reflect required actions per trainings and policy documents.
• Provide training and technical assistance to provider agencies on submission guidelines and denial management.
• Report suspected system issues to supervisor based on data analysis.

Skills

Claims processing

Billing

Medical coding

Education

High School Diploma/GED

Associate’s degree preferred

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

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.

Make an Impact

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) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook
• 401k with 5% employer match and immediate vesting
• Public Service Loan Forgiveness (PSLF) qualifying employer
• Quarterly stipend for remote work supplies

Qualifications

• High School Diploma/GED and two (2) years of experience in claims processing, billing, or medical coding; OR
• Equivalent combination of education/experience.
• Must have a valid driver’s license
• Must reside within North Carolina
• Must be able to travel within catchment as required.

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: October 12, 2026 at 11:59pm

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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