Claims Specialist

CCI Health Services’ mission is to deliver high quality, accessible care to our community members, leading the way to a more equitable health care system for everyone.

Position Summary

CCI is seeking a Claims Specialist to serve as a financial resource in support of the clinical services provided. The Claims Specialist will assure that services are promptly and accurately processed in accordance with all applicable Federal, State, and local regulations and guidelines, that claims are adjudicated in a timely manner, and customer’s needs are met in a professional and courteous manner.

Key Functions & Responsibilities

• Review and analyze encounters to ensure completeness, accuracy, adherence to all system edits (both core system and clearinghouse), and in compliance with all State, Federal, and/or contracted payer rules, terms, regulations, and guidelines.
• Ensures claims are processed in a timely manner, adhering to a standard of claim submission within five (5) days from the date of service, and follows up with individual and/or providers in those situations exceeding five (5) days from the date of service.
• Ensures any claims which are rejected by the clearinghouse, or the payer are addressed, resolved, and resubmitted with corrections.
• Addresses all denials from individual insurers in a timely, efficient, and collaborative manner, communicating with the health centers and support center personnel to effectively challenge denials and reverse the denial decision.
• Files appeal of denials in a timely and professional manner within the specified timeframes as published by regulations, rules, or guidelines of the payer.
• Responds in a timely and professional manner to all patient, insurance, or professional inquiries and concerns.
• Exhibit and apply knowledge of Commercial Indemnity guidelines in the processing, adjudication, and payment of claims.
• Maintain current understanding and application of all Medicare and state Medicaid compliance requirements regarding avoidance of allegations of fraudulent or false claims.
• Maintain productive and efficient communication with third-party payers which achieves expeditious claim adjudication and payment.
• Maintains consistent and timely follow-up with third-party payers and patients (as applicable) in unpaid claims beyond the expected payment date, ensuring each account is clearly and concisely documented with all efforts to expedite payment.
• Utilize online claim status applications in an effective and efficient manner in managing account follow-up.
• Make necessary adjustments to account balances with prior authorization from management to ensure the integrity of the account balance.
• Checks each insurance payment to ensure accuracy and compliance with contract discount terms.
• Evaluates patient financial status and established budget payment plans or eligibility for Sliding Scale consideration.
• Must ensure open and constructive coordination with health center personnel in maintaining accuracy in data elements and processing crucial to effective claims processing and account resolution.
• Must ensure adherence with all HIPAA Regulations and Compliance Regulations ensuring the protection of PHI (Patient Health Information).

Minimum Qualifications

• Minimum High School diploma, an AA or BS degree preferred or commensurate experience.
• Must have at least 2 years of relevant work experience in a Physician Practice/Hospital-based Physician Center/FQHC setting or can have an equivalent combination of training and experience to perform functions outlined for this position.
• Strong attention to detail.
• Must be familiar with hospital and or physician coding.
• Strong customer service skills - bi-lingual (English/Spanish) is a plus.
• Must be assertive and goal oriented.
• Familiarity with computerized systems is required.
• Must be a willing participant in ongoing educational activities and a contributing participant in staff meetings.
• Working on-site is an essential duty for the job.

Founded in 1972, CCI Health Services is a diverse and inclusive workplace grounded in community. Located in the Washington, DC Metro Area, each year CCI cares for more than 60,000 individuals in Montgomery and Prince George’s Counties. As a non-profit, CCI is committed to improving health equity through the provision of affordable primary care for all, across all stages of life. Visit ccicares.org for more information.