Claims Specialist (Managed Care) Full Time

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.

We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Position Responsibilities

Specific

• Track and report common source errors or technical issues for evaluation and remediation by product team
• Communicate key insights and findings to product team
• Evaluate ways to improve monitoring, discover issues and deliver better value to the customer
• Provide recommendations for possible process changes to optimize process and maximize performance
• Conduct audits of provider and member work streams to promote compliance, improve experience, optimize outcomes, and ensure high-value procedures are in place
• Investigate potential quality of care complaints, including tracking and trending areas of concern

General

• Maintaining timely and effective internal and external communication regarding assigned work/ tasks
• Logging, tracking, and ensuring completion of all work in compliance with contract service standards
• Tracking review completion of assigned work to ensure final closure/ resolution
• Managing high workload volumes, ensuring accuracy and compliance with contractual deadlines
• Ensuring all necessary information is available and organized for professional staff review/resolution
• Outreach as necessary for clarification or collection of additional information needed
• Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines

Competencies

Position Qualifications:

• Previous experience with claims, appeals and grievances for multiple lines of business (LOBs) including Medicare Advantage, Managed Medicaid, Dual SNP, & Commercial Lines of Business.
• Knowledge of current insurance benefit structures
• Knowledge and competency with claims payment review, edits and configuration
• Excellent oral and written interpersonal/communication
• Strong internal/external customer-service, organizational, multitasking, and teamwork skills
• Excellent analytical thinking/problem-solving skills
• Proficiency in Microsoft Office
• Ability to work effectively in a fast-paced environment with multiple priorities, deadlines, and workloads

Experience

• 2+ years of experience work for a Managed Care (Payer)

Physical Requirements

• Must be able to sit in a chair for extended periods of time
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
• Must be able to fluently communicate both verbally and in writing using the English language

Time Zone: Mountain or Pacific

Other Information

• Expected Hours of Work: Friday 8 am – 5 pm PST ; with ability to adjust to Client schedules as needed
• Travel: May be required, as needed by Client
• Direct Reports: None
• Salary Range: $48,000 – $75,000

EEO Statement

It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.