Claims Specialist 

Bronx, NY  

Schedule: M-F, 8:30am to 5:30pm  

Work Location: Hybrid 

Assignment Length: Undetermined, potential for Direct Hire 

  

FlexStaff is seeking a Claims Specialist for our client, a non-profit healthcare organization providing home and community-based healthcare and services for the elderly. This role is responsible for supporting department operations related to provider communication, pending claim review, reporting, auditing, and oversight activities.  

  

Responsibilities:  

Responsible for reviewing claims processed by the outside vendor, including resolving provider appeals/disputes.   Compiles claim reports  Investigates suspense conditions  Communicates and follows up with a variety of internal and external sources  Attends JOC meetings with providers as appropriate  Ensures that refund checks are logged and processed  Generates routine daily, monthly and quarterly reports  Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor  Analyzes patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditions  Other related duties as assigned by the supervisor  

  

Qualifications:  

Bachelor’s degree  Certified Professional Coder, a plus  Eight or more years of insurance experience within a healthcare setting, preferred  Proficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system  Knowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVS  Knowledge of MLTC/ Medicaid/Medicaid benefit, Member (Subscriber) enrollment & billing, Utilization Authorizations, Provider Contracting 

  

Additional Salary Detail  

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member’s base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).