Claims Specialist II

🔥 0 minutes ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $42.8k - $61.5k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

📋 Claims Specialist

🚫👨‍🎓 No degree required

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Trillium Health Resources

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Trillium Health Resources is a leading specialty care manager (LME/MCO) for individuals with serious behavioral health, intellectual/developmental disabilities, and traumatic brain injury in North Carolina. The organization is committed to investing in the health and well-being of the communities it serves, providing services such as preventive health screenings, crisis intervention, and tailored care management. Trillium focuses on enhancing access to mental health and substance use services for its members and ensuring support for vulnerable populations.

📋 Description

• Perform data analysis, auditing, and finalize adjudication results for claims designated for pre-payment review • Conduct post-payment review of claim adjudication results through research and knowledge of CMS, NC Medicaid, and Trillium billing guidelines and policies • Assist providers by phone or email with claims processing questions • Communicate with internal and external stakeholders to facilitate efficient claims resolution • Analyze and audit claims adjudication results for accuracy against NC Medicaid guidelines • Analyze and audit claim attachments and medical documentation required to adjudicate claims • Analyze, audit, and take appropriate action on claims delayed due to rejection errors • Identify adjudication errors, provider billing errors, and needs for technical assistance • Review and apply departmental training, published coverage policies, and NCDHHS documents • Provide training, education, and technical assistance to provider agencies regarding claim submission guidelines, denial management, system use, and updates • Recognize and report suspected system issues or concerns to the immediate supervisor

🎯 Requirements

• High School Diploma/GED and two (2) years of experience in claims processing, billing, or medical coding; OR equivalent combination of education/experience • Must have a valid driver's license • Must reside within North Carolina • Must be able to travel within catchment as required • Associate's degree in Healthcare Administration, Business, or a Human Services field preferred • Hospital claims experience and knowledge preferred • Experience in physical health claims processing or medical coding preferred • Experience working with Managed Care billing software preferred • Certified Professional Coder (CPC), Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS), or similar certification preferred • All candidates must pass a drug test as a condition of employment • Resume must include employer name, dates of service, average hours worked per week, essential job duties, education details, and licensure/certification information if applicable

🏖️ Benefits

• Competitive benefits • Work-from-home options for most positions • Flexible work schedules with management approval for some roles • Health Insurance with no premium for employee coverage • Flexible Spending Accounts • 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year • NC Local Government Retirement Pension (defined-benefit plan) • 401k with 5% employer match and immediate vesting • Public Service Loan Forgiveness (PSLF) qualifying employer • Quarterly stipend for remote work supplies