Remote Claims Specialist II – NC Medicaid Adjudication

Trillium Health Resources; Raleigh (NC); Remote; USD 43,000 - 62,000; Full time

Benefits offered by this job

Health Insurance with no premium for 


Remote work options

401k with 5% employer match

Job summary

Trillium Health Resources is seeking a Claims Specialist II to analyze and audit NC Medicaid claims and adjudication documentation for pre- and post-payment reviews. You will help resolve provider questions by phone or email and ensure compliance with CMS and NC Medicaid guidelines.

On a typical day you will analyze adjudication results, verify attachments, correct errors, train providers, and communicate with internal and external stakeholders to facilitate timely claims resolution.

Qualifications

• High School Diploma or GED and two (2) years of experience in claims processing, billing, or medical coding.
• OREquivalent combination of education and experience.
• Must have a valid driver’s license.
• Must reside within North Carolina.
• Must be able to travel within catchment as required.
• Must be legally authorized to work in the United States without requiring sponsorship for employment now or in the future (ex: OPT F-1, J-1).

Responsibilities

• 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.

Education

Associate’s degree in Healthcare Administration, Business, or a Human Services field

Tools

Managed Care billing software

Job description

Trillium Health Resources is seeking a Claims Specialist II to analyze and audit NC Medicaid claims and adjudication documentation for pre- and post-payment reviews. You will help resolve provider questions by phone or email and ensure compliance with CMS and NC Medicaid guidelines.

On a typical day you will analyze adjudication results, verify attachments, correct errors, train providers, and communicate with internal and external stakeholders to facilitate timely claims resolution.