Claim specialist jobs in Santa Fe, NM - 163 jobs

This job is a non-clinical resource that coordinates, analyzes, and interprets the benefits and claims processes for clinical teams and serves as a liaison between various departments across the enterprise, including but not limited to, Clinical Strategy, Sales/Client Management, Customer Service, Claims, and Medical Policy. The person in this position must fully understand all product offerings available to Organization members and be versed in claims payment methodologies, benefits administration, and business process requirements. **ESSENTIAL RESPONSIBILITIES** + Coordinate, analyze, and interpret the benefits and claims processes for the department. + Serve as the liaison between the department and the claims processing departments to facilitate care/case management activities and special handling claims. Communicate benefit explanations clearly and concisely to all pertinent parties. + Investigate benefit/claim information and provide technical guidance to clinical and claims staff regarding the final adjudication of complex claims. Research and investigate conflicting benefit structures in multi-payor situations. + Provide prompt, thorough and courteous replies to written, electronic and telephonic inquiries from internal/external customers (e.g., clinical, sales/marketing, providers, vendors, etc.) Follow-up on all inquiries in accordance with corporate and regulatory standards and timeframes. + Must have the ability to apply knowledge about the business operations of the area within the defined scope of the job. Assess benefit limitations in accordance with Medical Policy Guidelines. + Monitor and identify claim processing inaccuracies. Bring trends to the attention of management. + Assist with handling inbound calls and strive to resolve customer concerns received via telephone or written communication. + Work independently of support, frequently utilizing resources to resolve customer inquiries. + Collaborate with Clinical Strategy, Sales/Client Management and other areas across the enterprise to respond to client questions and concerns about care/case management and high-cost claimants. + Gather information and develop presentation/training materials for support and education. + Other duties as assigned or requested. **EDUCATION** **Required** + High School or GED **Substitutions** + None **Preferred** + Associate's degree in or equivalent training in Business or a related field **EXPERIENCE** **Required** + 3 years of customer service, health insurance benefits and claims experience. + Working knowledge of Highmark products, systems (e.g., customer service and clinical platforms, knowledge resources, etc.), operations and medical policies + PC Proficiency including Microsoft Office Products + Ability to communicate effectively in both verbal and written form with all levels of employees **Preferred** + Working knowledge of medical procedures and terminology. + Complex claim workflow analysis and adjudication. + ICD9, CPT, HPCPS coding knowledge/experience. + Knowledge of Medicare and Medicaid policies **LICENSES or CERTIFICATIONS** **Required** + None **Preferred** + None **SKILLS** + Knowledge of principles and processes for providing customer service. This includes customer needs assessment, meeting quality standards for services + Knowledge of administrative and clerical procedures and systems such as managing files and records, designing forms and other office procedures + The ability to take direction, to navigate through multiple systems simultaneously + The ability to interact well with peers, supervisors and customers + Understanding the implications of new information for both current and future problem-solving and decision-making + Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate and not interrupting at inappropriate times + Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems + Ability to solve complex issues on multiple levels. + Ability to solve problems independently and creatively. + Ability to handle many tasks simultaneously and respond to customers and their issues promptly. **Language (Other than English):** None **Travel Requirement:** 0% - 25% **PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS** **Position Type** Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely **_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._ **_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._ _As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy._ _Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._ **Pay Range Minimum:** $21.53 **Pay Range Maximum:** $32.30 _Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._ Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. 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