Claims Processing Specialist
PayMedix, Milwaukee, WI, United States
We are seeking a detail-oriented Claims Processing Specialist to support the Claims Processing Team in managing the day-to-day processing of claims received from Third-Party Administrators (TPAs). This role is essential to ensuring the accurate and timely handling of claims, contributing directly to efficient payment operations.
Key responsibilities include processing claim files, generating reports, responding to email inquiries, resolving support tickets, addressing bank return items, and preparing documentation for employer credits. The Claims Processing Specialist plays a critical role in maintaining smooth claims operations and ensuring service standards are met. This position reports to the Claims Processing Supervisor.
Essential Duties and Responsibilities To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Process claims files using multiple internal systems, TPA websites and interact with TPA representatives to ensure claims are processed accurately
Ensure claim errors are corrected prior to adjudication
Send various reports to employer groups and TPAs
Respond to emails from employer groups and TPAs
Review and solve tickets regarding customer complaints/inquiries, questions, and requests from employer groups, and claim adjustment requests from internal and external clients
Prepare documents for employer credits
Support special projects and ad-hoc assignments related to claims and operations efficiency
Create Ad hoc reports as needed
Perform other related duties as assigned
Qualifications
High attention to detail with strong analytical, organizational, documentation, and time-management skills
Proven ability to execute established processes and manage daily operational tasks independently
Maintains good working knowledge of system/internet and online tools used to process claims with the ability to learn and adapt to new systems quickly
Excellent written and verbal communication skills
Proven ability to manage multiple priorities effectively in a fast-paced environment
Demonstrated experience meeting deadlines and performing under pressure on a routine basis
Clear and professional communication skills with an aptitude for coordinating effectively between multiple teams
Collaborative mindset with the ability to work effectively across departments and communicate clearly with both internal and external stakeholders
Education/Experience
Bachelor’s degree preferred, or equivalent combination of education and relevant experience
Minimum of three (3) years of experience in medical claims processing
Customer service experience strongly preferred
Advanced skills in MS Office (Excel, Word, Outlook, and PowerPoint)
Strong knowledge of CPT, HCPCS, ICD-10, and claims adjudication processes
Experience in Medical/Health Insurance experience is preferred
Experience with claims management software, TPA portals, or other healthcare-related systems a plus.
Demonstrated track record of meeting accuracy and productivity targets in a high-volume processing environment.
Work Environment The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.
This is a
hybrid position : three days in the office and two days working remotely
The physical environment primarily involves working at a desk using computer and phone equipment
Occasional overtime or weekend work may be required for special projects or events
Able to live our mission, vision, and values
Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this office-based job. Reasonable accommodation may be made to enable individuals with disabilities to perform these functions.
Communicate verbally and professionally
Answer phones and interact with others
Walk occasionally around the office to perform job duties
Sit at a desk for extended periods
Use keyboard, monitor and telephone
Maintain close vision and the ability to adjust focus for reading and working on a computer
Disclaimer The information provided in this job description is intended to outline the general nature and level of work performed by employees within this classification. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required of employees assigned to this position.
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Key responsibilities include processing claim files, generating reports, responding to email inquiries, resolving support tickets, addressing bank return items, and preparing documentation for employer credits. The Claims Processing Specialist plays a critical role in maintaining smooth claims operations and ensuring service standards are met. This position reports to the Claims Processing Supervisor.
Essential Duties and Responsibilities To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Process claims files using multiple internal systems, TPA websites and interact with TPA representatives to ensure claims are processed accurately
Ensure claim errors are corrected prior to adjudication
Send various reports to employer groups and TPAs
Respond to emails from employer groups and TPAs
Review and solve tickets regarding customer complaints/inquiries, questions, and requests from employer groups, and claim adjustment requests from internal and external clients
Prepare documents for employer credits
Support special projects and ad-hoc assignments related to claims and operations efficiency
Create Ad hoc reports as needed
Perform other related duties as assigned
Qualifications
High attention to detail with strong analytical, organizational, documentation, and time-management skills
Proven ability to execute established processes and manage daily operational tasks independently
Maintains good working knowledge of system/internet and online tools used to process claims with the ability to learn and adapt to new systems quickly
Excellent written and verbal communication skills
Proven ability to manage multiple priorities effectively in a fast-paced environment
Demonstrated experience meeting deadlines and performing under pressure on a routine basis
Clear and professional communication skills with an aptitude for coordinating effectively between multiple teams
Collaborative mindset with the ability to work effectively across departments and communicate clearly with both internal and external stakeholders
Education/Experience
Bachelor’s degree preferred, or equivalent combination of education and relevant experience
Minimum of three (3) years of experience in medical claims processing
Customer service experience strongly preferred
Advanced skills in MS Office (Excel, Word, Outlook, and PowerPoint)
Strong knowledge of CPT, HCPCS, ICD-10, and claims adjudication processes
Experience in Medical/Health Insurance experience is preferred
Experience with claims management software, TPA portals, or other healthcare-related systems a plus.
Demonstrated track record of meeting accuracy and productivity targets in a high-volume processing environment.
Work Environment The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.
This is a
hybrid position : three days in the office and two days working remotely
The physical environment primarily involves working at a desk using computer and phone equipment
Occasional overtime or weekend work may be required for special projects or events
Able to live our mission, vision, and values
Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this office-based job. Reasonable accommodation may be made to enable individuals with disabilities to perform these functions.
Communicate verbally and professionally
Answer phones and interact with others
Walk occasionally around the office to perform job duties
Sit at a desk for extended periods
Use keyboard, monitor and telephone
Maintain close vision and the ability to adjust focus for reading and working on a computer
Disclaimer The information provided in this job description is intended to outline the general nature and level of work performed by employees within this classification. It is not intended to be an exhaustive list of all duties, responsibilities, or qualifications required of employees assigned to this position.
#J-18808-Ljbffr