Risk Management Claims Representative

Trillium Health Resources; Clayton (NC); Remote; USD 52,000 - 64,000; Full time

Benefits offered by this job

Work-from-home options

Health Insurance with no premium for员工

Flexible Spending Accounts

24 days PTO + 12 holidays

NC Local Government Retirement Pension

401k with employer match

Remote work supplies stipend

Job summary

Trillium Health Resources is hiring a Claims Specialist II to perform data analysis, auditing and finalize adjudication results for claims under NC Medicaid guidelines. The role supports providers by phone or email and coordinates with internal and external stakeholders to resolve claims efficiently.

The person will review claim submissions, attachments, and potential errors, ensuring accuracy and compliance with CMS and NC Medicaid policies, while providing guidance and training as needed.

Qualifications

• High School Diploma or GED and two years of experience in claims processing, billing, or medical coding.
• Associate's degree in Healthcare Administration, Business, or a Human Services field.
• Hospital claims experience and knowledge.
• Experience with Managed Care billing software.
• Certification CPC, CPB, CMRS or similar preferred.

Responsibilities

• Analyze and audit claims adjudication results to ensure accuracy per NC Medicaid guidelines.
• Analyze and audit claim attachments/medical documentation for adjudication.
• Identify adjudication errors and provider billing errors; escalate as needed.
• Provide training and technical assistance to provider agencies based on audit findings.

Skills

Claims processing

Data analysis

Auditing

Medical coding

Education

High School Diploma or GED

Associate's degree in Healthcare Administration/Business/Human Services

Tools

Managed Care billing software

Job description

Claims Specialist II

Pay Plan Title: Claims Specialist II Working Title: Claims Specialist II

Office Location: Remote within North Carolina

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.

Competitive benefits and work-from-home options for most positions

Every day, our work changes lives - from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.

Trillium Health Resources has a career opening for a Claims Specialist II to join our team! The Claims Specialist II performs data analysis, auditing and finalizes adjudication results for claims designated for pre-payment review and post payment review of claim adjudication results through research and knowledge of billing guidelines and policies established by CMS, and NC Medicaid as well as Trillium policies and procedures. This position is also responsible for assisting providers by phone or email with claims processing questions as well as communicating with internal and external stakeholders to facilitate efficient claims resolution.

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.
• flexible work schedules with some roles with management approval.

Benefits

• Work-from-home options available for most positions
• Health Insurance with no premium for employee coverage
• Flexible Spending Accounts
• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year
• NC Local Government Retirement Pension (defined-benefit plan)
• 401k with 5% employer match and immediate vesting
• Quarterly stipend for remote work supplies

Qualifications

High School Diploma or GED and two (2) years of experience in claims processing, billing, or medical coding; Must be able to travel within catchment as required.

Associate's degree in Healthcare Administration, Business, or a Human Services field (such as Psychology, Social Work, etc.)

Hospital claims experience and knowledge

Experience in the areas of physical health claims processing or medical coding

Experience working with Managed Care billing software

Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS) or similar certification preferred.

Deadline for Application: Open until filled