Medical Claims Specialist II — COB & Recovery Expert

Tier4 Group; Baton Rouge (LA); On-site; USD 42,000 - 66,000; Full time

Job summary

Tier4 Group is seeking an experienced Claims Specialist II to join our healthcare claims operations team in Baton Rouge, LA. You will investigate and resolve medical claims issues, process adjustments, and research COB to ensure accurate payments.

The role requires at least 2 years of hands-on medical claims processing experience and COB knowledge. You will collaborate with providers, members, and other departments to recover overpayments and improve claims accuracy.

Qualifications

• 2 years of hands-on medical claims processing experience.
• Knowledge of COB, edits, denial codes, benefits and payment information.
• Strong analytical, investigative and problem-solving skills.
• Excellent attention to detail and documentation accuracy.
• Strong written and verbal communication skills.

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 vs secondary coverage.
• Apply COB rules involving subscriber status, effective dates, plan types, Medicare coordination, and other factors.
• Communicate with members, providers, and other carriers to verify coverage and resolve issues.
• Identify overpayments and initiate refund or recovery processes.
• Review quality audit findings and complete required corrections within timelines.
• Maintain accurate and complete claims documentation.
• Partner with multiple departments to resolve complex issues.
• Assist with special projects, audits, system issues, training, implementations, and process improvements.

Skills

Analytical skills

Investigative skills

Problem-solving

Attention to detail

Communication skills

Prioritization

Education

High School Diploma or equivalent

Tools

Claims processing systems

Microsoft Excel / standard computer apps

Job description

Tier4 Group is seeking an experienced Claims Specialist II to join our healthcare claims operations team in Baton Rouge, LA. You will investigate and resolve medical claims issues, process adjustments, and research COB to ensure accurate payments.

The role requires at least 2 years of hands-on medical claims processing experience and COB knowledge. You will collaborate with providers, members, and other departments to recover overpayments and improve claims accuracy.