Claims Specialist at Accentuate Staffing

Responsibilities:

• Evaluate and determine claim coverage for benefits in accordance with policy and/or certificate provisions, and department procedures.
• Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
• Establish claim reserves and authorize payments within authority limits.
• Enter claim payments, reserves, and new claims on various computer programs, inputting concise yet sufficient file documentation.
• Contact and/or interview claimants, doctors, medical specialists, or employers to obtain additional information as needed.
• Manage time adequately to ensure proper turn around for all tasks such as new claims, pending claims, customer service requests, and audit feedback.
• Maintain quality and production standards as defined by procedures and management.
• Communicate with legal counsel on claims requiring litigation.
• Maintain claim files, such as records of settled claims and an inventory of claims requiring detailed analysis.
• Report overpayments, underpayments, and other irregularities.
• Ability to look at processes and offer suggestions for efficiencies.
• Work with teammates and supervisor to ensure the needs of the claimants are being met.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

Requirements:

• One year of claims adjudication or equivalent experience.

• Bachelor’s Degree is required.

• Must have NC Life License – will allow 90 days to obtain and will cover cost associated with examination.
• Complete FMLI Level 1 LOMA course and ACS course within 9 months of employment.
• Clear and concise verbal and written communication skills.
• Analytical, problem solving and organizational skills.
• Attention to Detail and Highly Dependable.
• Proficiency with MS Office applications, especially Word and Excel.