Claims Specialist

The Claims Specialist is primarily responsible for processing Medicare/Medicaid subrogation claims received from various external vendors in accordance with MSP laws and following internal client setup, as well as handling JIRA requests submitted by internal departments to assist with troubleshooting any claims adjudication related issue. Claims specialist is to act as Subject Matter Expert for all claims-related issues, testing and enhancements. Must report on site 5 days a weekKey ResponsibilitiesMedicare/Medicaid SubrogationBe the point of contact for anything Medicare/Medicaid relatedCommunicate with external vendors regarding subrogation processReceive, log and process all subrogation claimsProperly and timely respond to every demand letterCross-Functional CollaborationManage Claims Support email box and JIRA queue and ensure timely and proper responseAddress complex or escalated claims and work with client services and member services to ensure high levels of customer service.Client Implementation and System TestingLead claims-related components of new client implementations testingCoordinate and execute plan design testing for new clients, nee plans and changes to the existing plansCollaborate with IT, Implementation Teams, and Client Success team to resolve inconsistencies and validate claim adjudication accuracyServe as the subject matter expert (SME) for claims processing during audits, business enhancement meetings, and system change testingConduct regression testing when changes, updates, or corrections are implementedPerform post implementation claims monitoringClaims quality reviewPerform weekly ESI audit reversalsMonitor Unbalanced Claims weekly reportQualifications:Required3+ years of experience in claims processing or a related insurance fieldExcellent organizational, analytical, and problem-solving abilitiesAbility to work in a fast-paced environment with shifting priorities.Strong Microsoft Excel skillsStrong understanding of claims processing procedures, benefits administration, coordination of benefits (COB), and reimbursement methodologiesAbility to interpret policy documents, benefit plans, EOBs, and regulatory guidelinesPreferredAbility to interpret claims data and make informed decisions.Strong experience with HMS rules and regulations and Medicare/Medicaid subrogation claim processing.Strong experience in plan design and benefit configuration.Familiarity with Medicare/Medicaid claims rules, subrogation concepts, or state/federal insurance regulations is advantageousBenecard Services, LLCBenecard Services, LLC has been administering carve-out, fixed rate insured prescription drug benefit programs since 1990. Benecard is a full service, in-house prescription benefit administrator that includes mail and specialty drug dispensing. We are a premiere nationwide Prescription Benefit Administrator headquartered in Lawrenceville, New Jersey.Website: http://www.benecard.comBeneCard PBFBeneCard PBF provides self-funded prescription benefit program administration with a personalized approach through focused, clinical expertise. Our business model operates on a customized claim processing system offering unlimited capability and flexibility to respond to client needs in an evolving marketplace. Advanced clinical programs and advanced technology provide the framework to maximize the use of all data elements available. This allows BeneCard PBF to filter the information, focus on clinical opportunities and facilitate interaction between the physician, the pharmacist and the patient to effectively promote complete health care. Headquartered in Bonita Springs, Florida.Website: http://benecardpbf.comNational Vision AdministratorsFor over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health & Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey.Website: http://www.e-nva.com