Claims Coordinator

Claims Coordinator
 
POSITION OVERVIEW

FLSA:    Non-Exempt, Full Time

Department:    Claims

Primary Worksite:    6 West Colony Place, Durham, NC

Supervisory Responsibilities:    None

Reports to:    Claims, QA & Compliance Officer

JOB SUMMARY

The Claims Coordinator is responsible for overseeing and efficiently processing member benefit and insurance claims. You will work closely with insurance carriers, members, and healthcare providers to ensure that claims are handled in a timely and accurate manner. 
Supports DAN members throughout the claims process by coordinating with insurance carriers and facilitating timely and accurate claim handling. Calculates applicable benefits and prepares claim recommendations for underwriter review and final determination.

Common duties include reviewing claim forms, verifying information, contacting members and providers to gather additional information, developing recommendations, and forwarding claims to carriers for payment. The Claims Coordinator will also assist with subrogation and the coordination of claims among carriers.

CORE RESPONSIBILITIES

•    Verify coverage, calculate benefit payments, and communicate claim determinations to members and providers.
•    Review and validate claim submissions for accuracy, completeness, and compliance with applicable requirements.
•    Coordinate with members, insurance adjusters, and other stakeholders to obtain required documentation and information.
•    Review, compile, and organize claim documentation for submission to the appropriate carrier.
•    Process claims in a timely manner while maintaining accurate and complete records within the department’s claims management system.
•    Prepare claim recommendations (pay/deny) and forward processed claims to the appropriate carrier for determination.
•    Communicate with DAN and program assistance partners regarding complex, urgent, or ongoing cases.
•    Support members by helping ensure needed care and services are provided promptly and professionally; guide members through the claims process and assist in resolving issues or discrepancies.
•    Serve as a liaison between DAN Medical Services, DAN Claims, and third-party assistance companies for emergent cases and situations requiring coordinated support.
•    Participate in a rotating on-call schedule, including providing 24-hour emergency benefit verification support.
•    Pursue subrogation opportunities and other potential reimbursement avenues through third-party carriers.
•    Adhere to all policies and procedures outlined in the DAN Employee Handbook.
•    Perform additional duties and responsibilities as assigned.

MINIMUM QUALIFICATIONS
•    Bachelor’s degree or a minimum of 5 years of experience in claims, customer service, or a related field
•    Proficiency in Microsoft Office® applications
•    Strong verbal and written communication skills, including professional phone etiquette
•    Excellent organizational, time management, and problem-solving abilities with strong attention to detail
•    Ability to handle sensitive information with confidentiality and professionalism.
•    Ability to obtain and maintain required insurance licensing (training and associated costs provided by DSI

Work Environment
Hybrid work arrangement is available with this role, 2 days remote and 3 days in office, post the 90-day probationary period.