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Solis Health Plans · 2 days ago

Claims Specialist

Doral, FL, US

Full-time

Onsite

Mid, Senior Level

$22/hr - $24/hr

5+ years exp

Solis Health Plans is seeking a Claims Specialist to serve as a liaison between the plan, claims, providers, and various departments. The role involves resolving claims issues, ensuring accurate claims adjudication, and maintaining performance goals in areas of quality and production.

Health CareHealth DiagnosticsPersonal Health

Responsibilities

Serve as a liaison between the plan, claims, providers, and various departments to effectively identify and resolve claims issues

Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication

Review, research, solve and process assigned work. This would include navigating multiple computer systems and platforms (e.g. Verify pricing, prior authorizations, applicable benefits)

Audit check run and send claims for corrections

Ensure that the proper benefits are applied to each claim by using the appropriate tools, processes, and procedures (e.g. Claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan documents/ certificates tool)

Independently complete on a daily basis all documentation and communicate the status of claims as needed adhering to all reporting requirements

Communicate through correspondence with members and providers regarding claim payment or required information, using clear, simple language to ensure understanding

Meet and maintain the performance goals established for the position in the areas of quality, production, and attendance

Performs other duties as assigned

Qualification

Claims ProcessingSpanish FluencyMedical TerminologyAnalytical SkillsComputer ProficiencyCommunication SkillsOrganizational SkillsProblem-Solving SkillsTeamwork

Required

High school diploma / GED (or higher) OR 5+ years of equivalent working experience

Knowledge of Medical Terminology, coding, and diagnosis coding is helpful

Excellent verbal and written communication skills

Commitment to excellence and high standards

Strong organizational, problem-solving, and analytical skills

Able to manage priorities and workflow

Demonstrates a high level of professionalism in dealing with confidential and sensitive issues

Ability to work effectively, independently and in a team environment

Ability to deal effectively with a variety of individuals

Fluency in Spanish and English required

Proficiency in computer software (i.e. Microsoft Word, Excel, Power-Point, and Outlook) and the ability to learn new and complex computer system applications (including comfort using short-cut keys/demands)