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Claims Specialist
Claims SpecialistSolis Health Plans • Miami, FL, United States
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Claims Specialist

Claims Specialist

Solis Health Plans • Miami, FL, United States
29 days ago
Job type
  • Full-time
Job description

Job Title

To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to:

  • Serve as a liaison between the plan, claims, providers, and various departments to effectively identify and resolve claims issues.
  • Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication.
  • Review, research, solve and process assigned work. This would include navigating multiple computer systems and platforms (e.g. Verify pricing, prior authorizations, applicable benefits)
  • Audit check run and send claims for corrections.
  • Ensure that the proper benefits are applied to each claim by using the appropriate tools, processes, and procedures (e.g. Claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/ certificates tool)
  • Independently complete on a daily basis all documentation and communicate the status of claims as needed adhering to all reporting requirements.
  • Communicate through correspondence with members and providers regarding claim payment or required information, using clear, simple language to ensure understanding.
  • Meet and maintain the performance goals established for the position in the areas of quality, production, and attendance.
  • Performs other duties as assigned.

Qualifications & Education

  • High school diploma / GED (or higher) OR 5+ years of equivalent working experience.
  • Knowledge of Medical Terminology, coding, and diagnosis coding is helpful.
  • Excellent verbal and written communication skills.
  • Commitment to excellence and high standards.
  • Strong organizational, problem-solving, and analytical skills.
  • Able to manage priorities and workflow.
  • Demonstrates a high level of professionalism in dealing with confidential and sensitive issues.
  • Ability to work effectively, independently and in a team environment.
  • Ability to deal effectively with a variety of individuals.
  • Fluency in Spanish and English required.
  • Proficiency in computer software (i.e. Microsoft Word, Excel, Power-Point, and Outlook) and the ability to learn new and complex computer system applications (including comfort using short-cut keys/demands).

Working Conditions

  • The noise level in the work environment is usually moderate.
  • Interacts with health plan members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.
  • This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity.
  • The work is performed indoors.
  • All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed.
  • The work schedule is approximate, and hours/days may change based on company needs.
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Claims Specialist • Miami, FL, United States

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