Claims Sr. Representative - Direct Claims - Remote

POSITION SUMMARY

Serve as a subject matter expert (SME) to the Direct Claims team for resolution of member and client related issues.

Provide directive or resolutions to the less experienced team members.

Responsible for handling escalated and presidential claims received from internal departments.

Identify and recommend process and procedural improvements to leadership team.

Primary Functions


* Handling of Polaris cases that include, claims requiring additional research, navigate through appropriate system platforms to perform research and resolve claim issues.


* Serve as the direct claims point of contact for providing feedback results with internal and client audits.


* Analyze claims for potential fraud by member or pharmacy.


* Evaluate and maintain client service levels and performance guarantees for processing claims, including turn-around times and quality assurances.


* Provide support to the team with issues needing expertise assistance for a resolution of claim issues.


* Research and correspondence to members, internal departments, and external agencies regarding outstanding claims issues.

Compose letters to members or pharmacies for those claims with insufficient information or eligibility or benefit issues.


* Confirm patient eligibility and verify patient information matches system.

Update member's address to match claim form if necessary.


* Recognize repetitive problems or issues and escalate to senior leaders as needed.


* Special projects as needed.

Key Qualifications


* High School Diploma or GED required


* 3+ years relevant claims processing experience highly preferred


* Experience with MSC and CSP preferred


* Medicare Part D knowledge required


* Proficient with General PC knowledge: Microsoft Office, Internet, some experience with Excel, PowerPoint and SharePoint experience is highly encouraged.


* Advanced problem-solving skills: ability to diagnose a situation and make recommendations on a resolution.


* Strong attention to detail, written and oral communication skills.


* Ability to adapt in a dynamic work environment, learn quickly, solve problems and complete tasks with minimal supervision.

Candidate must reside in one of the following counties in Missouri or Illinois:


* Illinois Counties of Bond, Calhoun, Clinton, Jersey, Madison, Monroe, and St.

Clair


* Missouri Counties of Franklin, Jefferson, Lincoln, St.

Charles, St.

Louis, St.

Louis City and Warren

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 20 - 30 USD / hourly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

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