Claims Specialist II

Elite Technical is seeking a Claims Analyst to support our Healthcare payor client in a remote setting for a 3 month+ duration contract. Duties required to support the claims unit is as follows:

• Accurate processing of claims edits, determining primacy for the Coordination of Benefits (COB), adjusting previously paid claims and initiating procedures to recover funds on overpaid claims. Analyzing, investigating, and resolving problem cases; executing recovery processes; and completing special projects.
• Identifying primary vs. secondary coverage when a member has more than one health plan
• Reviewing and updating claims to reflect correct COB rules
• Applying COB primacy rules (subscriber status, effective dates, plan type, Medicare coordination, etc.)
• Communicating with members, providers, and other insurers to verify coverage details
• Correcting overpayments, initiating refunds or reprocessing, and maintaining accurate claim records
• Working within claims systems and following regulatory and compliance requirements (e.g., HIPAA)
• Reviews, research, and make necessary updates to claims that may include the following: recalculation of benefits to previously processed claims, the processing of claims edits, or initiation of refund requests, according to contractual benefits or provider reimbursement rules, ultimately providing a high degree of customer satisfaction.
• Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes pertaining to all claims (including our coordination with additional coverage plans) to process both coordinated and non-coordinated claims correctly. Requesting medical records may be required.
• Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.
• Research, investigates, and determines the correct order of benefits for payment to be made by the applicable plans and makes necessary corrections to COB records. Communicates to appropriate department(s) when Medicare has determined primacy incorrectly and ensures a letter is generated to notify Medicare.
• Analyzes, investigates, resolves problem cases (to include COB records, adjusting previously processed claims and requesting refund of overpaid claims). Reviews of all previously processed claims to ensure consistency in payments to maximize recovery of overpayments following corporate and departmental guidelines to ensure financial stability.
• Executes procedures to recover funds from providers, subscribers, or beneficiaries where overpayments have occurred to ensure accuracy of claims processing and financial stability.