Claims Specialist

About the role

• Job Title: Claim Specialist
• Client Location: 255 Technology Park, Lake Mary, FL 32746
• Contract Duration: 4+ months (High possibility of Extension)

Info about Schedules

• Candidates being selected need to be open for the contractor shift of either

9a-6p or 10a-7p or 11-8.

• If contractors are hired on, they have to be available for shifts like 11a-8p and 12p-9p. Please let candidates know this!

Looking for

• Candidates must have reimbursement experience that is within the past 6 months
• Prior authorization - submission, review, support, completion, verification
• Appeal - submission, review, support, completion, verification, coordination

Reimbursement - investigation, verification

Job Summary

The primary function/purpose of this job:-

Verify member submitted claims forms, member's eligibility and pharmacy information is complete and accurate, updating system information as needed.

Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions.

Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside of Express Scripts. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met.

Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy.

May be required to work on special projects for claims team.

Scope of Job

• Reimbursement verification of enrollments

Minimum Qualifications to Enter the Job

• Formal Education and/or Training: High school diploma or equivalent required, some college or technical training preferred

Years of Experience

Two years' experience in P.B.M. environment is helpful but not required.

Knowledge and Abilities

• Strong data entry and 10-key skills
• Retail pharmacy, customer service experience helpful but not required
• PC and MS Office literate
• Strong attention to detail
• Excellent retention and judgment ability
• Proficient written and oral communication skills
• Ability to work in fast-paced, production environment
• Reliable, self-motivated with excellent attendance
• Team player who has the ability to stay on task with little supervision

Additional Information

All your information will be kept confidential according to EEO guidelines.