Claims Specialist Trainee

Job Summary

Processes Wellness, Accident and Sickness insurance claims and determines the nature and validity of claims by reviewing policy status, patient eligibility, and supporting medical documentation; submits claims for payment or further investigation; provides prompt customer service for inquiries from policy holders, providers, or agents regarding claim status

Principal Duties & Responsibilities

Under immediate supervision and in accordance with established policies and procedures, reviews and processes Wellness, Accident and Sickness insurance claims based on information submitted by policy holders; determines the nature and validity of claims by reviewing policy status, patient eligibility, and supporting medical and other documentation

Keys claims data while interpreting coding and medical terminology in relation to diagnoses and procedures; uses multiple core administration databases, systems and subsystems to process and transmit claims for payment or further investigation

Provides prompt customer service to policy holders, providers and other internal company entities regarding claims; documents phone calls in the system and follows-up on issues if needed; contacts insured or other appropriate persons to verify the accuracy and completeness of information on claims forms and related documents, responds to inquiries from policy holders, providers, agents regarding claim status and policy provisions

Provides back-up coverage for other teams as required, maintains databases and prepares and extracts information using software systems; performs various clerical duties as assigned, such as filing, photocopying, typing, maintaining databases and preparing and extracting information using software systems

Performs other related duties as required

Specialist - Education & Experience

High School Diploma or Equivalent, 1 year of work experience, Experience and proficiency using Microsoft Office Suite software, or an equivalent combination of education and experience.

Experience with medical terminology (Preferred)

Job Knowledge & Skills

• Knowledge of principles and processes for providing customer and personal services; this includes needs assessment, meeting quality standards for services, and evaluation of customer satisfaction

• Knowledge of administrative and clerical procedures an systems such as word processing, managing files and records, and other office procedures and terminology

• Skill in giving full attention to what other people are saying; taking time to understand the points being made; asking questions as appropriate

• Skill in understanding the implications of new information for both current and future problem solving and decision-making

• Skill in using mathematics to solve problems

• Skill in selecting and using training/instructional methods and procedures when learning new policies, procedures, concepts or products

• Skill in managing one’s own time and actively looking for ways to help people

• Positions requiring the use of bilingual skills (if applicable to this position): Fluency in Spanish with the ability to translate documents

Organizational Competencies

Acting with Integrity, Communicating Effectively, Pursuing Self-Development, Serving Customers, Supporting Change, Supporting Organizational Goals, Working with Diverse Populations