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Medicare Claims Specialist

Job Posting
Medicare Claims Specialist
Greensboro, NC • Operations

Job Summary

Reporting to the Director of Operations, Provider Services, and Claims, this individual will manage all open claim events to ensure the proper department and/or service provider actions are taking place in a timely fashion in order to provide an exceptional customer service experience.

Major Work Activities

Claims Communication:

Handle Inbound/Outbound calls, emails, and ticketing related to open claims with an emphasis on a timely, sensible resolution for plan, provider, and member.
Communicate in a clear, precise professional manner with all parties internal and external in order to ensure a quality customer service experience.
Instill customer confidence by delivering on promises such as callbacks and/or delivering on agreed to action items.
Provide departmental assistance as needed such as but not limited to claims education, provider education, and general service network support efforts.
Claims Resolution:

Identify trends that are either currently impacting provider or member service or may do so in the future.
Assists as a liaison between TPA partner, internal team members, and partner organization providing leadership for claims, provider disputes, and benefits administration.
Facilitates guidance and support to all claims and operations personnel towards resolution of claim-related problems.
Supports internal plan team members with the resolution of daily issues.
Work with other departments to identify and resolve problems leading to the incorrect payment of claims.
Assist management in the identification and coordination of the necessary claims, provider dispute resolution, and service training needs.
Serves on various committees and attends required meetings.
Perform other duties and projects as assigned.


Minimum Qualifications

Required Education

Associates Degree or equivalent


2-4 years of experience supporting claims processing, claims system configuration functions, and experience with Medicare Advantage plans.

Knowledge, Skills, and Abilities

Understanding of Medicare benefit designs, benefit structures, medical policies, pay policies, and their impact on claims/benefit configuration and claims processing.
Experience with Medicare health plan operations.
Experience with Microsoft Office Suite, including Outlook.
Excellent written, analytical, and oral presentation skills.
Demonstrated exceptional active listening and communication skills
Problem-solving skills.
Ability to work independently.
Ability to meet deadlines.
Ability to effectively present information and respond to questions from peers and management.
Preferred Qualifications


Bachelor's degree in healthcare, business, or healthcare-related field


Certified Professional Coder (CPC)


2-4 years of experience within a Medicare health plan, managed care organization, or third-party administrator.

Knowledge, Skills, and Abilities

Intermediate Microsoft Word
Intermediate Microsoft Excel
Intermediate Microsoft Access
Project Management

Time:  Full time
Salary:  Salary
Category:  Clinical/pharmacy/quality

Updated: 12/21/2020 7:46:36 AM

Job Contact:
Michael Abner

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7800 McCloud Road
Greensboro, NC 27409