Claims Specialist

Are you looking for a dynamic position in a growing organization? Are you a people-person who thrives on cultivating new relationships over the phone and helping others? Do you want a fast-paced, team environment with room for growth? If so, VBA is looking for you.

JOB SUMMARY

As a Claims Specialist, you are responsible for determining reimbursements for out-of-network claims, processing adjustments and auditing manual claims. A Claims Processing Specialist successfully manages claims from submission through payment and interacts with Member Services Representatives to answer escalated member issues for out-of-network claims and adjustments. This role includes making decisions about eligibility and payments by assessing policy coverage and completion of submission. Additional opportunities are available as we expand our network, depending on your positive contributions and ability to adapt to change.

ESSENTIAL JOB FUNCTIONS

• Review out-of-network claims for completeness of submission.
• Validate member eligibility and policy details through use of Claims system.
• Proficient use of document management technology (Content Server) for securing and storing documents through their lifecycle.
• Works jointly with team members to manage all parts of the reimbursement process (processing claim requests, validation, payment, adjustments, audits and research); tasks can vary daily as assigned.
• Research and respond to escalated member questions regarding out-of-network and adjustments.
• Act as a liaison for member issues including benefit eligibility, claims questions, and customer satisfaction.
• Work with Claims Processing Team Lead and Benefit Relations Teams to resolve member, provider and lab reimbursement and claim inquiries.
• Complete projects as assigned by department lead or other departments.
• Perform activities and functions of related lower-level personnel as assigned or required.

*The above statements describe the general nature and level of work being performed by individuals assigned to this classification. This is not intended to be an exhaustive list of all responsibilities and duties required of this position.

QUALIFICATIONS

• Associate degree or equivalent work experience. Bachelor’s degree is preferred.
• At least 2 years of full-time customer service experience.

• 1 year claims processing experience, preferably in a healthcare field.

KNOWLEDGE, SKILLS AND ABILITIES

• Proficient in MS Office Suite – Word, Excel, Outlook and Teams
• Proficiency in insurance plan rules
• Ability to use resources to answer questions and solve problems
• Strong analytical, problem solving and decision-making skills
• Ability to work independently with minimal supervision or cooperatively as part of the team
• Ability to influence and effectively communicate with diverse personalities
• Effective organizational and time management skills
• Ability to work well with all levels of management and staff while maintaining a professional and diplomatic demeanor

WORK ENVIRONMENT/PHYSICAL DEMANDS (include but are not limited to)

• This is a remote position within the Pittsburgh, PA area.  In-office may occur periodically based on business need.
• Work is performed in a home office environment and may require:
• occasionally lifting 0 – 20 pounds.

To perform this job successfully, an individual must be able to perform the essential job functions satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the primary job functions described herein.  Since every duty associated with this position may not be described herein, employees may be required to perform duties not specifically spelled out in the job description, but which may be reasonably considered to be incidental in the performing of their duties just as though they were actually written out in this job description.

This is a full-time position. Days and hours of work are Monday through Friday 8:00AM to 4:00 PM with occasional overtime.

This position is currently remote. Our office in Carnegie, PA will remain accessible for use as needed. Selected candidate will be required to complete training periodically in-office for the first 3 weeks (hybrid training) of employment and must be available to report to our office occasionally for team/company meetings.

Computer and software provided by VBA. Employee must have access to reliable internet connection and a quiet workspace.

Membership in OPEIU Local No. 457 is required.

Starting pay rate is $20-22.00 per hour.

Full-time, permanent VBA employees receive an exceptional benefits package including:

• Health and Dental benefits with minimal employee contribution.
• Employer paid Vision, Short Term and Long Term Disability, and Life Insurance benefits. Vision plan offers generous allowances, no copays, and two materials per year for eligible employee and dependents.
• 401k employer matching up to 6% following six months of service, vesting after five years of service.
• Generous time off and leave package