Claims Specialist II

· Specialist performs pre- and post-payment audits of external claims; ensures that the company rigorously manages claims for external services; ensures that claims are paid according to contracted rates, for approved services, and are otherwise appropriate and correct; reviews and responds to claims submitted on appeal.
· Support a remote claims processing team, including coordination with an offshore team based in India. · Assisting with end-to-end claims process, ensuring accuracy, timeliness, and compliance.
· Assist with Processing & Review on complex claims, including Physician and Facility claims, medical claims, Medicare based cpt codes for federal inmates, FBOP side of the business
· Provide expert guidance on CPT codes, UB04s, HICFA forms, DRGs, ICD-10, and appeals.
- Address and resolve escalated claims issues and inquiries.
- Collaborate with internal teams via Microsoft Teams, phone, and email.
- Maintain documentation and reporting for claims activities and quality metrics.
Communicate to Claims Leadership any issues that would impede the accurate and timely processing of claims.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.

· Must have high school diploma or GED, bachelors degree highly preferred
· 8-10+ years of Medicare claims processing experience with knowledge of CPT4 and ICD10 codes, UB04s and HCFA Forms
· Strong knowledge of Physician and Facility Claims, Audit Codes and Billing, DRGs and ICD-10, Appeals Processes ·
· Proven experience in a leadership, supervisory or quality assurance role. ·
· Working knowledge of Medicare medical insurance terminology, procedure, diagnosis codes, fee schedules and HIPPA requirements ·
· Experience interacting with clients and building professional relationships.
· · Preferred background in government contracts, correctional facilities or healthcare facilities. -
· experience with Excel, Adobe & outlook
· Must be able to apply principles of critical thinking to a variety of practical and emergent situations and accurately follow standardized procedures that may call for deviations.

-Degree
-Experience working with or within the prison system, including federal, county, or state correctional facilities, government contracts
-Background in non-commercial insurance claims (e.g., government-funded programs, correctional healthcare, etc.).
-experience working with an offshore team

Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.