Claims Specialist II

P & A Administrative Services, Inc; Village of Williamsville (NY); Sur place; USD 60 000 - 80 000; Plein temps

Résumé du poste

P & A Administrative Services, Inc. is seeking a Claim Specialist II to adjudicate reimbursement requests for participants with high volumes and strict deadlines. You will ensure accuracy, adhere to HIPAA and ERISA guidelines, and manage complex claim adjudication duties across multiple plan types.

The role emphasizes timely processing, data integrity, and collaboration with teams to optimize claims workflows while maintaining compliance and quality service.

Qualifications

• High School Diploma or equivalent.
• Knowledge of ERISA guidelines preferred

Responsabilités

• Process claims in a timely manner (within 1-2 days) in accordance with P&A’s policies, procedures and plan documents.
• Coordinates responses for routine phone inquiries, written correspondence, and internal questions related to claim processing inquiries.
• Draft and send manual adverse determination letters to inform participants of the need for additional information, or to afford them the right to appeal, per plan rules.
• Adjudicate card transactions that fail auto-review and determine if additional information is required to approve the transaction.
• Review and process requests for claim or balance modifications.
• Review letters of medical necessity and make approval/denial determinations as per regulatory requirements.
• Review HIPAA authorizations and enter data into software systems in accordance with departmental policies and procedures.
• Enter banking information into software platforms to facilitate direct deposit transactions in accordance with departmental policies and procedures.
• Monitor and take appropriate action on ACH reversal requests
• Review and process claims flagged as potential duplicates and ensure they are processed correctly.
• Review claims queues regularly processing in order of priority to ensure timely claim turnaround in accordance with departmental policies and procedures.
• Investigates and responds to all claim inquiries promptly and professionally.
• Make recommendations to increase the efficiency and accuracy of claims processing and training practices.

Formation

High School Diploma or equivalent.

Description du poste

Description

The Claim Specialist II position plays a pivotal role in the success of our organization, by adjudicating all reimbursement requests for our participants in a timely and accurate manner. Working with high volumes and strict turnaround times, the Claim Specialist II understands the intricacies of the products we offer, as well as the IRS regulations that govern our abilities to pay or deny a claim. The position is responsible for adhering to HIPAA guidelines and is responsible for performing complex claim adjudication duties related to Section 125, 129, 132, 105(h) plans, Lifestyle etc. to maximize quality, quantity, and total customer/client satisfaction.

Effective performance of all duties and responsibilities of the position will ensure accurate and timely completion of required tasks and compliance with required timelines.

Requirements

ESSENTIAL FUNCTIONS

• Process claims in a timely manner (within 1-2 days) in accordance with P&A’s policies, procedures and plan documents.
• Coordinates responses for routine phone inquiries, written correspondence, and internal questions related to claim processing inquires.
• Draft and send manual adverse determination letters to inform participants of the need for additional information, or to afford them the right to appeal, per plan rules.
• Adjudicate card transactions that fail auto-review & make the determination if additional information is required to approve the transaction.
• Review and process requests for claim or balance modifications.
• Review letters of medical necessity and make approval/denial determination as per regulatory requirements.
• Review HIPAA authorizations and enter data into software systems in accordance with departmental policies and procedures.
• Accurately enter banking information into software platforms to facilitate direct deposit transactions in accordance with departmental policies and procedures.
• Monitor and take appropriate action on ACH reversal requests
• Review and process claims flagged as potential duplicates and ensuring they are processed correctly.
• Review claims queues regularly processing in order of priority to ensure timely claim turnaround in accordance with departmental policies and procedures.
• Investigates and responds to all claim inquiries promptly and professionally.
• Make recommendations to increase the efficiency and accuracy of claims processing and training practices.

OHER FUNCTION(S)

• Champion P&A Group values and policies.
• Maintain data protection, privacy, security and maintain HIPAA compliance for participants and clients.
• Completes any additional assignments as requested by the executive/management team members
• Provide mentoring/support of team and/or identify/deliver training for team
• Ad-Hoc reporting, analysis and presentations as required

MINIMUM REQUIREMENTS

EDUCATION / EXPERIENCE

• High School Diploma or equivalent.
• Knowledge of ERISA guidelines preferred

SKILLS/KNOWLEDGE/COMPETENCIES

• Must be able to analyze, interpret, evaluate and apply departmental policies, procedures, and administrative practices, recognize potential for client and company exposure, and be creatively involved in formulation of solutions.
• Knowledge of reimbursement account programs such as Sections 125, 129, 132, 105h, and Wellness plans.
• Solid oral and written communication skills with ability to convey one’s message with diplomacy and tact
• Ability to effectively interact, present information, and respond to questions from customers, colleagues and management
• Ability to effectively manage multiple priorities utilizing effective organizational and time management practices
• Self-starter with the ability to work independently in a fast-paced environment with critical deadlines
• Ability to develop and maintain positive relationships with both internal and external customers
• Strong computer skills, including Microsoft Office
• Strong attention to detail
• Must be able to independently set priorities along with making and meeting deadlines and schedules
• Ability to apply critical thinking skills to provide solutions to problems and administration of assigned plans

TRAVEL

• No travel is required for this role

WORKING CONDITIONS

Fast-paced work environment; flexibility to work schedules as required due to changing business demands. Occasional overtime is required. The work environment is moderately sedentary and typical of general office conditions with regard to standing, sitting, walking and lifting; no adverse conditions.

An equal opportunity employer and a smoke, drug and alcohol-free workplace.

OTHER

Completes any additional assignments and projects as requested by management.

This job description is designed to cover a general list of responsibilities and expectations for this role and does not contain a complete listing of activities, duties or responsibilities that are required for the role. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time with or without advance notice.