Medical Claims Specialist I

MET Healthcare Solutions; Houston (TX); Hybrid; USD 40,000 - 56,000; Full time

Job summary

MET Healthcare Solutions in Houston, TX seeks a Claims Eligibility Specialist I to analyze level I claims information to determine eligibility in the dispute resolution process. The role is hybrid, requiring presence in the office 2-3 days a week, with a full-time schedule from 8am to 5pm, Monday through Friday.

Responsibilities include reviewing EOBs and remittance details, composing compliant correspondence, and maintaining organized claim files while staying current with regulatory

Qualifications

• Experience reviewing all types of medical claims, EOBs, and payment remittances.
• Understanding of insurance reimbursement rules.
• High attention to detail.
• Ability to work across multiple operating systems.
• Strong written and verbal communication skills.

Responsibilities

• Analyze Explanation of Benefits (EOB) and remittance documents to determine eligibility for the dispute resolution process.
• Compose correspondence in compliance with regulatory requirements and internal policies.
• Stay up to date on industry-specific regulations to ensure appropriate strategies.
• Maintain physical and electronic files for all claims determined eligible.

Skills

Attention to detail

Communication skills

Regulatory knowledge

Multi-OS experience

Job description

Job Description

Job Description

MET Healthcare Solutions is seeking a Claims Eligibility Specialist I to join our fast-paced organization in Houston, Texas (just north of Houston Heights). The Claims Eligibility Specialist I will be responsible for analyzing level I claims information to determine eligibility in the dispute resolution process in accordance with established federal regulations and company policies and procedures.

Responsibilities of the Claims Eligibility Specialist I may include but are not limited to:

• Analyze Explanation of Benefits (EOB) and payment remittance documents submitted by healthcare providers and insurance carriers to determine which level I claims are eligible for the dispute resolution process.
• Compose correspondence in accordance with regulatory requirements (and internal policies in procedures) in a clear, concise, and grammatically correct manner.
• Stay up to date on industry specific regulations, ensuring that appropriate strategies are in place.
• Maintain physical and electronic files for all claims determined eligible.

These responsibilities are a condensed list of the full scope of the job description and are subject to change depending on the company's demand.

• Experience reviewing all types of medical claims, EOBs, and payment remittances (e.g. HCFA 1500, Outpatient/Inpatient UB92, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
• Understanding of insurance reimbursement rules.
• Ability to work at a high level and display high attention to detail.
• Ability to work across multiple operating systems.
• Ability to maintain confidentiality and professionalism in difficult situations.
• Strong written and verbal communication skills with the ability to explain reasoning effectively.

The Claims Eligibility Specialist I position is offered as a hybrid position to those candidates that have completed the required training and are meeting the weekly expectations set for the position. The hybrid position requires your presence in our corporate office (just north of Houston Heights area) 2-3 times per week. Working a hybrid schedule is dependent on each individual's productivity and training level and is not guaranteed for any individual not meeting the hybrid schedule requirements.

This is a full-time position, Monday-Friday from 8am-5pm.

A healthcare management group, URAC-accredited as an independent review organization (IRO). Over 20 years of experience helping control costs, and mitigate regulatory compliance by providing superior administrative and medical expert services to improve the quality of healthcare functions nationwide. Making a difference in healthcare.

Company Description

A healthcare management group, URAC-accredited as an independent review organization (IRO). Over 20 years of experience helping control costs, and mitigate regulatory compliance by providing superior administrative and medical expert services to improve the quality of healthcare functions nationwide. Making a difference in healthcare.