Health Operations Claims Specialist
$73,000–$78,000 year
On-siteNew York City, New York, United States or New York, United States
Job Summary
Evaluate claims for eligibility, provider contracting rules, and plan design while researching third-party administrator policies. Conduct member outreach to resolve inquiries and communicate with facilities regarding complex submissions and documentation needs. Self-assign CRM cases during high-volume periods and document root cause analyses for management reporting. Collaborate with vendors to troubleshoot issues and identify workflow improvements for interdepartmental efficiency. Effectively utilize the member database to verify eligibility and benefits, ensuring accurate tracking and timely updates.
Required Qualifications
- 2+ years of work experience in health insurance claims, claims operations, or health billing
- Extensive knowledge of claim processing policies and procedures, including hospital/medical claims
- Understanding of ICD-10 coding
- Understanding of CPT codes
- Understanding of HCPCS codes
- Understanding of DRG coding
- Understanding of place of service
- Understanding of provider ids (TINS, NPIs)
- Understanding of amounts paid
- Understanding of out of pocket costs
- Strong knowledge of medical terminology
- Strong knowledge of ICD/CPT coding
- Strong knowledge of per diem and DRG reimbursement
- Prior knowledge with healthcare regulations and claims compliance requirements preferred
- Excellent verbal, written communication skills
- Analytical skills
- Problem-solving skills
- Ability to identify trends and recommend process improvements
- Experience accurately interpreting information from contractual and technical perspectives
- Ability to work on multiple projects with competing priority levels
- Proficiency with MS Office applications (Word, Excel, PowerPoint)
- Strong organizational and time management skills
- Ability to maintain confidentiality and exercise discretion when handling sensitive information
- Effective communicator with experience partnering with senior leaders and external partners
- High degree of professionalism, integrity, and accountability
- Demonstrated commitment to continuous learning, quality improvement, and operational excellence
- Strong actively listening skills
- Attention to detail
- Commitment to accuracy when reviewing claims, documentation, and benefit information
- Ability to work independently while contributing to team objectives
- High Reasoning Ability
Desired Qualifications
- Prior knowledge with healthcare regulations and claims compliance requirements
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