Medical Claims Specialist II — COB & Recoveries

Tier4 Group; Baton Rouge (LA); On-site; USD 55,000 - 75,000; Full time

Job summary

Tier4 Group is seeking a Claims Specialist II to join our medical claims operations team. You will investigate and resolve medical claims issues, process adjustments, and research Coordination of Benefits (COB) to ensure accurate payments.

The role requires at least 2 years of hands-on medical claims processing experience, strong analytical skills, and attention to detail. You will collaborate with providers, members, and other departments to drive accurate outcomes and recoveries.

Qualifications

• Minimum 2 years of hands-on medical claims processing experience.
• Strong understanding of healthcare claims processing and adjudication.
• Experience researching and resolving claims discrepancies.

Responsibilities

• Review, research, and process medical claims.
• Investigate edits, denial codes, processing codes, and payment discrepancies.
• Adjust and reprocess previously paid claims when necessary.
• Recalculate benefits based on plan and provider reimbursement requirements.
• Research COB and determine primary versus secondary insurance coverage.
• Apply COB rules involving subscriber status, effective dates, plan types, and Medicare coordination.
• Communicate with members, providers, and other insurers to verify coverage and resolve issues.
• Identify overpayments and initiate refund or recovery processes.
• Maintain accurate and complete claims documentation.

Skills

Medical claims processing

Coordination of Benefits (COB)

Analytical skills

Research & problem solving

Attention to detail

Communication skills

Claims adjustments

Recovery & refunds

Education

High School Diploma or equivalent

Job description

Tier4 Group is seeking a Claims Specialist II to join our medical claims operations team. You will investigate and resolve medical claims issues, process adjustments, and research Coordination of Benefits (COB) to ensure accurate payments.

The role requires at least 2 years of hands-on medical claims processing experience, strong analytical skills, and attention to detail. You will collaborate with providers, members, and other departments to drive accurate outcomes and recoveries.