Senior Claims & Appeals Specialist

ourhrconnect; Columbia (SC); Sur place; USD 38 000 - 54 000; Plein temps

Avantages offerts par ce poste

Subsidized health plans

401k retirement savings plan with  公司匹

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts

Résumé du poste

National Alliance is seeking a detail-oriented Customer Service/Claims Specialist to respond to complex inquiries, review claims and appeals, and adjudicate issues in alignment with contract standards. You will research underlying causes, identify prevention measures, and handle sensitive information with discretion.

In this role, you will enter claims into our system, ensure accurate coding, and maintain quality and productivity.

Qualifications

• 3 years of customer service experience, including 1 year of claims or appeals processing experience OR Bachelor's Degree in lieu of work experience.
• High School Diploma or equivalent.
• Good verbal and written communication skills; Strong customer service skills; Basic business math; Ability to handle confidential information.

Responsabilités

• Review claims or appeals issues, complaints, and inquiries referred by claims customer service representatives to determine if desk procedures and guidelines were followed.
• Research to identify underlying causes, and determine ways to prevent and correct such causes.
• Identifies and reports potential fraud and abuse situations.
• Research and respond to complex customer inquiries, ensuring that contract standards and objectives for timeliness, productivity and quality are met. Handles situations that require adaptation of response or extensive research.
• Examine and process claims and/or non-medical appeals according to business/contract regulations, internal standards and examining guidelines.
• Enter claims into the claim system after verification of correct coding of procedures and diagnosis codes. Ensure claims are processed according to established quality and production standards.
• Provide feedback to management regarding customer issues. Maintain accurate records concerning issues. Follow through on complaints until resolved or report to management as needed.
• Maintain knowledge of procedures and policies. Assist with process improvements by recommending improvements in procedures and policies. Assists in training claims customer service representatives.

Connaissances

Customer service

Communication skills

Formation

High School Diploma

Outils

Microsoft Office

Description du poste

National Alliance is seeking a detail-oriented Customer Service/Claims Specialist to respond to complex inquiries, review claims and appeals, and adjudicate issues in alignment with contract standards. You will research underlying causes, identify prevention measures, and handle sensitive information with discretion.

In this role, you will enter claims into our system, ensure accurate coding, and maintain quality and productivity.