Claims Specialist

Claims Specialist

The Claims Specialist ensures the accurate entry of inpatient and outpatient claims per the data entry guidelines and ensures the timely processing of claims per the adjudication rules for accurate payment or denial. They are also responsible for the accurate use of referral guidelines and benefit plans. Other duties include filing; assisting outside providers, members, and staff regarding claims related questions or issues; and assisting internal staff on complex claims related questions and problems. The Claims Specialist performs under the general direction, guidance, and supervision of the Claims Supervisor.

GHC-SCW is a quality driven cooperative built on collaboration, community involvement, innovation, and belonging. In dedication to the health and well-being of our employees, we offer a comprehensive benefits package that includes health and dental insurance, along with paid short-term disability, long-term disability, and life insurance. Additional benefits include a flexible spending account, employee assistance programs, tuition reimbursement, pet insurance, eyewear discounts, and more.

Job Specific Minimum Qualifications

• High school graduate or equivalent required.
• One (1) to two (2) years' administrative experience in an insurance, healthcare, financial or relevant environment. Previous experience in claims resolution / processing or closely related work in an insurance or healthcare environment is highly desirable.
• Knowledge of or ability to learn and accurately apply claims processing techniques, procedures and practices in a timely manner required.
• Ability to develop and maintain a working knowledge of claims adjudication rules, computer functions, usual and customary costs, discounts, rates, capitated payment arrangements, contract deadlines, provider changes and benefit plans required.
• Knowledge of medical terminology preferred.
• Knowledge or CPT -4 and ICD -10 coding is desirable.
• Knowledge of and ability to use computers including billing system software, database, word processing, email, and calendar programs.
• Experience with EPIC systems is desirable but not required.
• Good verbal and written communication skills required.
• Good organizational skills required. Must be detail oriented and work with a high degree of accuracy.
• Good customer services skills required, including the ability to build and maintain effective working relationships with internal and external customers.
• Ability to maintain patient confidentiality required. Knowledge of or ability to learn HIPAA requirements.
• Ability to work independently with general supervision required.
• Ability to type accurately required.
• Ability to use a 10-key calculator accurately required.
• Ability to sit and stand intermittently required.
• Ability to use a keyboard extensively required.

The incumbent knows and abides by all GHC-SCW organizational and departmental policies, sets personal standards and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner.

Our Mission Statement : We partner with members and the communities we serve to maximize health and well-being.

Our Vision : As a local, not-for-profit, member-owned Cooperative, we are the most trusted resource for lifelong health and well-being in the communities we serve.

Our Values :

We believe :

Group Health Cooperative of South Central Wisconsin is proud to be an equal opportunity employer. GHC-SCW considers candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.