Evry Health is seeking a Claims Specialist. Claims Specialists are responsible for the end-to-end claims adjudication process. This includes testing claim configuration and benefit set up to review of the claim form, verification of eligibility, verification of coordination of benefits with other insurance carriers and finalizing claim determination based on the health benefits plan. Claims Specialists have responsibility to audit auto-adjudicated claims to ensure claim accuracy. They also ensure that claims are processed in accordance to State and Federal regulations and meet the company’s contractual obligations. Claims Specialists are responsible for writing and maintaining the desk top procedures associated with claim adjudication. This role reports to the Vice President of Operations with oversight from the Claims Team Leader.
We are on a mission to bring humanity to health insurance. Our high-technology health plans expand benefits, increase access and transparency, and feature a personalized, human approach. We strive to ensure members live happier, healthier lives.
Evry Health is the major medical division of Globe Life (NYSE:GL). Globe Life has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, Globe Life has earned an A (Excellent) rating or higher from A.M. Best Company.
Roles and Responsibilities
- Responsible for the review and processing of claims within the claims transactional system, according to plan benefits and contractual reimbursement terms.
- Follows established policies and procedures to pay, pend for additional information, or deny claims.
- Process claims subject to Coordination of Benefits (COB) according to plan benefits, COB rules and contractual reimbursement terms
- Accountable to meet and maintain established department production and quality standards.
- Create claim test cases, execute, and report on the results.
- Identify and communicate defects or claim system issues to those responsible for configuration.
- Work with configuration to remediate and retest defects.
- Identify and communicate inventory issues to department’s management.
- Works with internal departments, vendors, business partners, providers, etc. to help coordinate problem solving in an effective and timely manner.
- Develop and maintain desk top procedures related to claim adjudication.
- Audit auto-adjudicated and/or manually processed claims.
- Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins.
Experience and Skills Desired
- You have a minimum of 3 years' medical claim adjudication/examination experience, working within a health insurance carrier, health insurance TPA, or equivalent.
- You have knowledge of medical and insurance industry terminology including CPT/ICD-10, HCPCS and Revenue Codes.
- You possess strong attention to detail and problem-solving skills with a high level of accuracy.
- You have experience writing desk top procedures.
- You are an excellent communicator, both verbally and in writing.
- You can perform comfortably in a fast-paced, deadline-oriented work environment.
- You are proficient in Microsoft Office applications Word, Excel, Outlook OneNote, etc.
- You have prior experience using a CRM, preferably Salesforce.
- You have prior experience with claim testing and or/auditing.
- You collaborate and support business and operational units such as Customer Service, Medical Management and Appeals and Grievance.
- Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred.
- Bonus: Plexis/Quantum Choice experience.
Benefits Package
- Competitive salary
- Comprehensive health, dental, and vision insurance as well as life and disability
- Retirement savings plan with company match
- Generous time off/vacation
- Professional development opportunities
- Flexible work environment
Telecommuting Requirements
- This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas.
- Must live in the United States within the CST or EST time zones.
- Company business hours are weekdays 9-5 CST.
- Required to have a dedicated work area established that is separate from other living areas and provides information privacy.
- Ability to keep all company sensitive documents secure.
- Must live in a location that receives an existing high-speed internet connection/service.
Originally posted on Himalayas