Claims Operations Specialist
SmithRx
full-time
Posted on:
Location Type: Remote
Location: United States
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About the role
- Responsible for ensuring timely completion of non-electronically processed claims such as direct member reimbursement claims and commercial out-of-network claims.
- Ensure claims approvals and/or denials are made in accordance with company practices and procedures. Timely execution on member communications at scale, including mail-outs through our third-party mail vendor.
- Maintain reimbursement queue to meet the department's SLA’s. Completion of assigned claim cases in accordance with daily expectations.
- Sustain integrity of all existing claims processes by ensuring all process documentation is up to date.
- Participate in process improvement and quality assurance opportunities.
- Collaborate and provide cross-functional support to account management, member support, and other customer success teams.
- Act as a liaison between the clinical team and the member for denied reimbursements, initiating the prior authorization (PA) process to ensure proactive member support.
- Participate in internal meetings to help support initiatives and projects.
- Ability to prioritize and complete high-volume cases/claims.
Requirements
- 2+ year of experience in a healthcare claims role, preferably in a pharmacy setting or licensed as a pharmacy technician.
- Prior working knowledge of medical or pharmacy claims processing.
- Excellent organization skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
- Microsoft Excel skills required.
- Impeccable attention to detail and accuracy in work.
- Strong problem solving, written and verbal communication, and interpersonal skills
- Ability to work independently as well as part of an extended, cross-functional team
- Self-driven, results-oriented work ethic with a positive outlook
- Ability to take initiative with little to no direction
Benefits
- Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life and AD&D Insurance
- 3 Weeks Paid Time Off
- Paid Company Holidays
- Paid Parental Leave Benefits
- Flexible Spending Benefits
- 401(k) Retirement Savings Program
- Short-Term and Long-Term Disability
- Wellness Benefits
- Commuter Benefits
- Employee Assistance Program (EAP)
- Well-stocked Kitchen In Office Locations
- Professional Development and Training Opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
claims processingmedical claims processingpharmacy claims processingprior authorizationreimbursement processingquality assuranceprocess improvementattention to detailorganization skillsproblem solving
Soft Skills
communication skillsinterpersonal skillsability to prioritizeself-drivenresults-orientedinitiativeteam collaborationindependencetime managementcoordination
Certifications
pharmacy technician license