Claims Specialist

Claims Specialist

Why is Health Advocate a great place to work? For starters, Health Advocate employees enjoy helping people every single day. Employees are given the training they need to do their jobs well, and they work with supervisors and staff who are supportive and friendly. Employees have room to grow, and many of Health Advocate's supervisors are promoted from within the company. Join our award winning team!

Responsible for handling escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members; handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner; handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.); ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations

Provide first-line assistance for member's questions relating to post-service coverage of medical treatment or services which includes researching and resolving benefit claims issues, billing discrepancies, coding errors, insurance claims processing issues, and educating members on the components of their benefit plan coverage which ensuring adherence to corporate and department policies and procedures

Handle escalated and complex cases in a timely manner to identify opportunities to resolve the issue by working with plan documents, carriers, providers and members

Research plan information and identify where there may be conflicting information which may include escalating to supervisor or other levels of management for clarification and assistance

• Research billing issues to determine the possible cause of the error and assist with claims resubmission when needed to correct the issue

Assist members with dental related claims cases ensuring the claim is resolved or escalated in a timely manner

Handle a variety of behavioral health claims cases (e.g., substance abuse, residential treatment, autism, eating disorders, etc.) in an accurate and timely manner

Assist members with setting up payment arrangements and discounts which may include reaching out to healthcare providers to determine payment options

Utilize a variety of resources to research and resolve billing issues (e.g., plan documents, summary plan documents, benefits summaries, open enrollment material interpretation of benefits, understanding of medical, dental vision and behavioral health coverage, etc.)

Handle cases that require complex coordination of benefits issues among several carriers (e.g., motor vehicle, Medicaid, Medicare due to disability, disability administrator, etc.)

Assist with billing and claims adjudication process ensuring internal best practices are followed

Remain current on knowledge of Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA), Health Spending Accounts (HSA), and benefits Summary Plan Descriptions (SPD) to resolve billing issues

Assist team member with questions ensuring they have a clear understanding of workflow, subject matter and claims best practices

Exercise exceptional customer service skills in an effort to optimize each contact with the member

Ensure that claims are processed in strict adherence to established policies, procedures, quality standards as well as applicable federal laws and regulations

Know and support approved departmental and corporate policies and procedures relating to claims issues

Based on department need, mentor new employees regarding claims process and internal procedures

Participate in piloting departmental process improvements ensuring to provide any feedback to management

Participate in systems user testing providing feedback in a timely manner

Assist in resolving routine program quality issues by identifying issue(s) and researching in a timely manner

Research and evaluate billing issues to determine the possible cause of the error ensuring to assist the client with claims resubmission correct the issue

As needed, contact healthcare providers to gather documentation (e.g., bills, medical records, etc.) ensuring to notify management if the request cannot be obtained

Follow claims research through until resolution

Document all claims issues thoroughly maintaining department files and appropriate databases

Continuously evaluate the status of all work efforts, ensuring all tasks are prioritized to assist in providing timely and quality services

Assist in monitoring issue trends, escalating such trends to supervisor to determine appropriate actions necessary to eliminate future occurrences and improve service levels

Establish and maintain a professional relationship with internal / external customers, team members and department contacts

Cooperate with team members to meet goals or complete tasks

Provide quality customer service that exceeds customer expectations and improves level of service being provided

Treat all internal / external customers, team members and department contacts with dignity / respect

Escalate to supervisor any situation outside the employee's control that could adversely impact the services being provided

This position will be exposed mainly to an indoor office environment and will be expected to work near or around computers, telephones, and printers with a workspace that is free and clear of interruptions and distractions.

The nature of the work in this position is sedentary and the incumbent will be sitting most of the time.

Essential physical functions of the job include fingering, grasping, pulling hand over hand, and repetitive motions to utilize general computer software / hardware continuously throughout the work day

Essential mental functions of this position include concentrating on tasks, reading information, and verbal / written communication to others continuously throughout the work day

The job description documents the general nature and level of work but is not intended to be a comprehensive list of all activities, duties, and responsibilities required of job incumbents

Consequently, job incumbents may be asked to perform other duties as required

Also note, that reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above

Please contact your local Employee Relations representative to request a review of any such accommodations

Applicant for this job will be expected to meet the following minimum qualifications.

High School Degree or GED required

Associate degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field is preferred.

Minimum of two years customer service, healthcare, or claims experience required.

Basic Knowledge of MS Word and Excel required

Must score acceptably on job related testing

Ability to pass standardized interview

Based on program may need to be bilingual in English, Spanish, etc.

Knowledge of the following is preferred :

Affordable Care Act (ACA) (Marketplace Navigation and Exchange plan review and comparison)

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Medicare (Part A, Part B, Part D, Advantage and MediGap Plans)

Compare and contrast benefit plan options (Open Enrollment, New Hire, Qualifying Life Event (QLE), and other Special Enrollment Periods)

Group Benefits (Fully Insured vs. Self-Insured)

Medical Benefits (CDHP / HDHP, PPO, POS, and HMO Plans)

Pharmacy Benefits

Dental Benefits

Behavioral Health Benefits

Vision Benefits

FSA / HSA and HRA Benefits

Long Term and Short Term Disability and Long Term Care

Individual Health Plans

Short Term Plans

Health Advocate is the nation's leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.

Physical Requirements : This position is primarily on-site and requires the ability to move throughout the workplace to provide in-person counseling and wellness support. The role involves periods of sitting for one-on-one or group sessions, as well as standing or light movement during group activities, workshops, and team-building events. Essential physical functions include speaking, hearing, and manual dexterity for documenting case notes, navigating computer systems, and facilitating wellness interventions. Occasional lifting of light materials (up to 15 pounds) may be needed for wellness activities or event setup. Frequent use of a computer is required, including typing, mouse navigation, and viewing digital content. Visual acuity is necessary for reading client records, electronic documentation, and conducting virtual sessions when needed.