Senior Claims Specialist - VirginPulse

Now is the time to join us! 

Who are you?

We are seeking an experienced and highly skilled Senior Claims Specialist to join our claims processing team. As a Senior Claims Specialist, you will play a pivotal role in ensuring the accurate and efficient processing of healthcare claims, overseeing complex cases, and providing guidance to claims specialists. 

In this role you will wear many hats, but your knowledge will be essential in the following:  

• Claims Adjudication: Lead the adjudication of complex and high-dollar claims, applying advanced knowledge of policies, procedures, and guidelines.
• Claims Review: Conduct in-depth reviews of disputed or escalated claims, collaborating with internal teams and external stakeholders to reach fair and timely resolutions.
• Quality: Ensure a high level of quality in claims processing by consistently achieving a financial accuracy rate of 99% and a procedural accuracy rate of 97%, adhering to established guidelines and procedures.
• Documentation: Ensure accurate claims information is recorded in claims and patient notes, including accurate indexing, and archiving of documents to facilitate easy retrieval.
• Investigation: Investigate and resolve discrepancies and issues related to claims, ensuring prompt and fair resolution. Provide feedback to leadership on how to prevent discrepancies from occurring on future claims.
• Communication: Provide timely and concise updates on the status of assigned claims, highlighting any potential issues or complex cases that may require additional attention or guidance as well as proposed solutions.
• Process Improvement: Identify opportunities for process enhancements, lead process improvement initiatives, and collaborate with cross-functional teams to streamline workflows.
• Mentorship: Provide guidance and training to claims specialists, fostering their professional development and ensuring consistent and accurate claims processing.
• Policy Analysis: Analyze and interpret complex contracts and benefit documents to ensure accurate claims processing and compliance.
• This role will require a high level of customer service support to our members via inbound/outbound calls as well as member walk-ins with key focus on an empathetic resolution-oriented approach. 
• Customer Escalations: Handle escalated customer inquiries and complaints, demonstrating expert knowledge and exceptional problem-solving skills.
• Stay Informed on Procedures: stay up-to-date with company-wide processing procedures and group-specific processing requirements, ensuring that claims processing remains compliant and efficient with the latest industry and organizational standards.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

What you bring to the Personify Health team:

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including:

• Education: High School diploma or general education degree (GED).
• Experience: A minimum of 3-5 years of progressive experience in medical claims processing.

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

• Expertise: In-depth knowledge of healthcare insurance terminology, policies, and procedures, with a proven track record of handling complex claims.
• Leadership: Display leadership qualities by fostering a culture of teamwork, knowledge-sharing, and continuous improvement within the claims processing team.
• Analytical Skills: Advanced analytical and problem-solving abilities to tackle complex claims issues.
• Communication: Exceptional written and verbal communication skills, including the ability to communicate complex topics clearly.
• Adaptability: Demonstrated adaptability to evolving priorities, workflows, and regulations in the healthcare industry.
• Team Player: Collaborative attitude and willingness to work effectively in a team-oriented environment.
• Technology: Proficiency in relevant computer software and claims processing systems.

No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you!

Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice.

We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing.

In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges up to $28.00 per hour. Note that salary may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other benefits.