Job Description

Job Description

Bilingual Medical Claims Specialist

Must be fluent in Spanish

Summary:

Responsible for working in a fast-paced environment and having strong interpersonal and communication skills, attention to details, outstanding ability to multi-task and prioritize, and strong analytical skills. Performs administrative tasks related to client health premiums and out of pocket medical expenses, interacts with clients to provide information in response to inquiries about products and services, and handle and resolve complaints by performing the following duties.

Duties and Responsibilities include the following.

• Leads the customer service and/or claims team.
• Provides customer service and will processes medical claims for specific programs.
• Processes or adjust medical insurance claims in accordance with policies and procedures.
• Answers phones and respond to client inquiries related to payments made on their behalf to medical providers.
• Answers phones and responds to medical provider inquiries related to payments made or due to behalf of program clients.
• Makes outgoing calls to medical providers and insurance companies, or the like.
• Responsible for having the ability to read explanation of benefits, claim forms and healthcare terminology.
• Identifies, researches, resolves claim issues, and requests for additional documentation.
• Promotes teamwork and service delivery success.
• Ensures contractual performance guarantees related to payment processing timeliness and accuracy are met.
• Ensures contractual performance guarantees related to various means of client communications are met such as phone, email, and mail.
• Processes medical payments for clients.
• Assists in the client appeals process as backup.
• Creates and updates financial batch records as the backup for processing by accounting.
• Manages workflow for the program to ensure service levels are achieved.
• Approves letter queue as backup when needed for outgoing mail.
• Updates policy and procedures for department.
• Works with client’s that have high medical utilization.
• Recommends process improvements.
• Recognizes, documents and alerts the manager of escalated issues.
• Reviewing and denying pending W9 claims.
• Point person on staff for questions.
• Performs other duties as assigned.

Education/Experience:

• Associate's degree or equivalent or 4+ years of related experience

Specialized Training:

• Knowledge of medical insurance practices including enrollment, payment terms related to insurance premiums and out of pocket expenses, benefits coordination with other insurance coverage, and ensuring payer of last resort. Prior lead experience preferred.

Certificates and Licenses:

• Medical coding/billing strongly preferred.