Claims Specialist III

The Claims Specialist III functions in an important way within the Claims department. This position helps with processing and recouping as well as auditing. The Claims Specialist III helps identify errors and defects and resolve issues created by them. The incumbent is a self-starter who has keen attention to detail. They have the capacity to apply knowledge accurately and efficiently.

This role is currently hybrid in nature with in office attendance required 3 days a week on site at our corporate office located in Frisco, TX. Please note that this role will require onsite attendance 5 days a week starting in Spring/Summer 2027.

EXPECTED WORK AND PREFORMANCE

• Responsible for various claims duties including but not limited to:
  • Reprocessing of 1st submission claims with issues.
  • Processing refund and recoupments.
  • Completing W-9 updates.
  • Assisting with escalated portal issues that the contact center is unable to handle.
  • Managing member and provider claim research issues submitted by the Contact Center.
• Responsible for training duties including but not limited to:
  • Create training curriculum and materials based on identified needs.
  • Conducting new hire training, refresher training, and ad hoc training for team members needing focused training support.
  • Monitor training activities, evaluate program success, and adjust to improve outcomes.
• Responsible for auditing duties including but not limited to:
  • Completing client audits based on their request for funds schedule.
  • Completing claim team member monthly audits.
  • Completed ad hoc audits (focused, team member, provider, procedure, etc.)
• Reduce defects via pro-active identification of error issues as it relates to pre-payment of claims through adjudication and trends and recommending solutions to resolve these issues.
• Supports all department initiatives in improving overall efficiency.
• Performs additional duties as required and assigned, including but not limited to special projects as needed.

QUALIFICATIONS

Required

• Advanced computer skills and experience with MS Applications – Adobe, Excel, Word, Outlook
• Skillful with computer programs and can readily learn the ropes in the use of current office applications and Careington systems.
• Claims processing background within the medical or dental industry.

Preferred

• Associate degree or equivalent combination of education and experience.

SKILLS

• Extremely organized with the ability to effectively manage multiple tasks.
• Initiative-taking and the ability to work independently with minimal supervision.
• Aptitude to work in a deadline driven environment.
• Ability to communicate clearly, orally and in writing, with the ability to effectively interact with internal and external contacts.
• Capability to apply knowledge after training so claims are researched and resolved appropriately.
• Strong work ethic and ability to adapt to new directions as business plans evolve.
• Works accurately on the input of data, aims to work faultlessly.
• Has strong discipline and pays attention to procedures, agreements, and document flows.
• High level of efficiency, finding a good balance between quality and quantity.
• Ability tow ork discreetly with confidential (dental) information.

PHYSICAL REQUIREMENTS

Work is performed in an office environment and requires the ability to operate standard office equipment and keyboards. Must have the ability to walk short distances.

Required to stand, walk, and sit; talk or hear, both in person and by telephone; use hands to finger, handle or feel objects or controls; reach with hands and arms. Regularly required to stoop, kneel, bend, crouch and lift up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, depth perception, color vision and the ability to adjust focus.