Job Description
The Healthcare Claims Representative is responsible for responding to phone
calls from participants, families, insurance representatives, and internal staff with any questions
or concerns that they may have. This role requires calls to be made on any participant
statements to ensure that we receive a claim to process for our participants. Evaluates claims
and administers prompt and accurate resolution of claim issues, supports the claims submission
process, and upholds the organization’s standards for exceptional customer service and
compliance within the program.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Respond promptly and professionally to participants, family, and insurance inquiries
related to claims and billing.
Review and verify participant insurance coverage and eligibility.
Assist in processing claims accurately and within the time frames established by
management using the claims processing system.
Demonstrate a thorough understanding of matching appropriate authorizations to
claims and tracking missing authorizations.
Master and utilize a thorough understanding of such items as HCPC modifiers and their
effect on reimbursement, coordination of benefits (COB), appropriate billing guidelines
for anesthesia claims, hospital stays, ambulance and other services.
Communicate with internal personnel, vendors, providers, and billing representatives
about claim-related issues.
Work as a team in resolving claims issues or special projects
Report any inconsistencies that are identified in regard to internal department policies
and procedures to management
Provide administrative support including data entry, scanning, and filing as needed.
Perform other duties as assigned.
Maintain confidentiality and comply with HIPAA and PACE program requirements.
Participate in department meetings, training, and process improvement initiatives.
EXPERIENCE AND EDUCATION:
Education: High school diploma or GED required
Associate's degree in health administration, Billing, or related field preferred.
Experience: 1–2 years of experience in medical billing, claims processing, or healthcare customer
service, with familiarity in Medicare/Medicaid billing.
Must have reliable transportation, a valid driver's license, and the minimum state required
calls from participants, families, insurance representatives, and internal staff with any questions
or concerns that they may have. This role requires calls to be made on any participant
statements to ensure that we receive a claim to process for our participants. Evaluates claims
and administers prompt and accurate resolution of claim issues, supports the claims submission
process, and upholds the organization’s standards for exceptional customer service and
compliance within the program.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Respond promptly and professionally to participants, family, and insurance inquiries
related to claims and billing.
Review and verify participant insurance coverage and eligibility.
Assist in processing claims accurately and within the time frames established by
management using the claims processing system.
Demonstrate a thorough understanding of matching appropriate authorizations to
claims and tracking missing authorizations.
Master and utilize a thorough understanding of such items as HCPC modifiers and their
effect on reimbursement, coordination of benefits (COB), appropriate billing guidelines
for anesthesia claims, hospital stays, ambulance and other services.
Communicate with internal personnel, vendors, providers, and billing representatives
about claim-related issues.
Work as a team in resolving claims issues or special projects
Report any inconsistencies that are identified in regard to internal department policies
and procedures to management
Provide administrative support including data entry, scanning, and filing as needed.
Perform other duties as assigned.
Maintain confidentiality and comply with HIPAA and PACE program requirements.
Participate in department meetings, training, and process improvement initiatives.
EXPERIENCE AND EDUCATION:
Education: High school diploma or GED required
Associate's degree in health administration, Billing, or related field preferred.
Experience: 1–2 years of experience in medical billing, claims processing, or healthcare customer
service, with familiarity in Medicare/Medicaid billing.
Must have reliable transportation, a valid driver's license, and the minimum state required
💡 Quick Summary
Seeking a career-building opportunity? The Care Coordinator position is now open for candidates interested in the Data Entry Jobs sector. This role in New York City offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Data Entry Jobs is a plus.
