Claims Specialist

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

•
Prior authorization – submission, review, support, completion, verification

• Appeal – submission, review, support, completion, verification, coordination

• Reimbursement – investigation, verification

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