Healthcare Claims Specialist

Position Overview
We are seeking a Healthcare Claims Specialist with strong hands-on experience in medical claims processing and Coordination of Benefits (COB). The ideal candidate will be responsible for determining the correct order of benefits when members have multiple insurance coverages and ensuring claims are processed accurately.
Key Responsibilities
Process and review medical claims and claims edits accurately.
Determine primary vs. secondary insurance coverage under COB rules.
Apply COB rules involving Medicare and commercial insurance carriers.
Research and correct claims with inaccurate COB information.
Adjust and reprocess previously paid claims when necessary.
Investigate claim issues, denials, edits, and processing errors.
Identify and resolve claim overpayments.
Initiate refund and recovery requests from providers, subscribers, or beneficiaries.
Review previously processed claims to identify potential overpayments.
Communicate with members, providers, Medicare, and other insurance carriers to verify coverage.
Request and review medical records when required.
Perform quality audits and make required corrections within established timelines.
Maintain accurate claim records while following HIPAA and company compliance requirements.
Complete special claims-related projects as assigned.
Required Qualifications
High School Diploma or equivalent.
2+ years of medical claims processing experience.
Hands-on Coordination of Benefits (COB) experience – REQUIRED.
Experience determining order of payment/primacy between Medicare and commercial insurance.
Knowledge of primary and secondary insurance coverage.
Experience with claims adjustments, reprocessing, and overpayment recovery.
Strong analytical, research, and problem-solving skills.
Good written and verbal communication skills.
Ability to manage multiple priorities in a remote environment.
Working knowledge of PC/software applications.
Must-Have Experience
Medical Claims Processing + COB + Medicare/Commercial Insurance + Primary/Secondary Determination
Ideal candidate: A Claims Specialist/Claims Analyst/Claims Processor who has directly worked on COB claims, determining which insurance pays first and correcting claims based on Medicare and commercial carrier coverage.

Work arrangement
Yes