Claims Specialist

Connectiverx - Hanover, NJ

Full-time

Onsite - Hanover, NJ

Ambulatory Health Care Services

About the position

The Claims Specialist at ConnectiveRx LLC is responsible for processing medical claims from patients and healthcare providers. This role requires meeting productivity and quality standards while utilizing various systems to manage claims and respond to inquiries. The position involves verifying claim accuracy, consulting on complex cases, and providing feedback to improve processes.

Responsibilities

• Verifies the accuracy and completeness of claim forms and attachments, such as EOBs, EOPs, SPPs, and pharmacy receipts.
• Enters information into adjudication systems as required and processes claims based on system adjudication and business rules.
• Consults with the Team Lead or Supervisor for complex claims or clarification of business rules.
• Obtains missing information by contacting customers using standard scripts or form letters.
• Processes claims and/or answers phones based on volume.
• Refers requests for escalation as needed and engages other internal areas to resolve issues.
• Provides input and feedback to improve processes, procedures, and training.
• Completes other projects and tasks as assigned.

Requirements

• High School diploma or GED required.
• 1+ years in a health care or case management setting.
• Experience in pharmacy benefits, health care insurance, and/or medical billing is a must.
• Health care or pharmaceutical experience, particularly in medical claims processing, billing provider, or insurance environment.
• Knowledge of EOB and EOP statements.
• Prior experience in a high-volume processing setting is a plus.
• Experience with Third-Party systems (SelectRx, Pro-Care, FSV) is preferred.
• Fluent in English/Spanish is a plus.
• Knowledge of Medical Claims processing/billing coding is required.
• Strong communication skills, both written and verbal.
• High level of empathy and emotional intelligence for customer service.
• Detail-oriented with thoroughness and accuracy in tasks.
• Adaptability to various situations and effective navigation of challenges.
• Critical thinking and problem-solving skills.

Nice-to-haves

• Experience with Third-Party systems (SelectRx, Pro-Care, FSV) is preferred.
• Fluent in English/Spanish is a plus.