Russell Tobin · 4 hours ago
Claims Specialist
United States
Contract
Remote
Entry, Mid Level
$21/hr - $23/hr
2+ years expRussell Tobin is seeking a Provider Reimbursement and Claims Specialist who will be responsible for reviewing, auditing, and pricing claims. The role requires strong attention to detail and the ability to interpret provider documents to ensure accurate and timely claim payments.
ConsultingHuman ResourcesLegalStaffing Agency
Responsibilities
Conduct detailed, manual review and pricing of claims (e.g., out-of-network or non-standard claims) using provider contracts, pricing methodologies, and regulatory mandates where standard auto-adjudication fails
Interpret hospital, medical group and provider contracts with depth to accurately determine payment methodologies, fee schedules, and reimbursement rates for complex claims
Keep the department's claim pend queue inventory current, clearing edit queues by processing claims according to regulatory requirements and plan benefits
Review claims thoroughly for correct CPT/HCPCS, ICD-10 coding, necessity, limitations, and exclusions based on claims policies
Independently investigate and resolve complex claim edits and making informed decisions regarding clearing edits and claim payment
Work independently to resolve difficult or complex transactions, managing smaller claims-related projects from start to finish without continuous supervision
Act as a Subject Matter Expert (SME) for claims, actively identifying system problems, performing User Acceptance Tests (UAT) of new and existing provider contracts, and collaborating with management to enhance claims operations
Qualification
Required
Demonstrated experience in manually reviewing and pricing claims, including interpreting provider contracts and fee schedules for non-standard payment methodologies
Hands-on working knowledge and background using claims processing systems
Experience in medical claims procedures, governing rules, and all aspects of pricing and adjudication
Knowledge of CPT/HCPCS, ICD-10 claims coding, and medical terminology
Proven ability to work independently, manage time effectively, and make sound decisions in ambiguous situations
Minimum Education: A high school diploma or equivalent is required
2-3 years of experience processing claims
Knowledge of CPT codes
Ability to utilize pricing tables and understand how to price a claim
Healthcare industry experience
Preferred
Hospital or physician billing background
Health plan or TPA claims processing background
Ability to analyze large data sets
Benefits
Comprehensive healthcare coverage (medical, dental, and vision plans)
Supplemental coverage (accident insurance, critical illness insurance and hospital indemnity)
401(k)-retirement savings
Life & disability insurance
An employee assistance program
Legal support
Auto, home insurance
Pet insurance
Employee discounts with preferred vendors
Company
Russell Tobin
Russell Tobin is a staffing and recruiting company that provides recruitment and staffing advisory services.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
John Woronowich, JD
Vice President - Search, Staffing & Embedded Partnerships
Ashley Steger
Director of Talent Acquisition and People Operations- Embedded Partnerships
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