What are the responsibilities and job description for the Claims Specialist position at Detego Health?
**Job Title:** Claims Specialist
**Department:** Claims
**Reports To:** Complaince and Strategy Supervisor
**Job Summary:**
The Claims Specialist Reviews is responsible for reviewing, analyzing, and responding to claim denials and appeals. This role requires expertise in medical coding, claims adjudication, and regulatory guidelines to ensure accurate, timely, and compliant resolution of member and provider disputes.
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**Key Responsibilities:**
* **Appeals and Denials Handling:**
* Review and process appeals from members, providers, and regulatory agencies regarding denied or underpaid claims.
* Investigate the reason for denials and determine appropriateness of original decision based on plan policy, clinical guidelines, and coding rules.
* Draft written responses to appeals, ensuring clarity, compliance, and alignment with medical necessity and policy terms.
* **Coding Reviews:**
* Perform detailed analysis of CPT, HCPCS, ICD-10, and DRG codes to validate claim accuracy and support appeal decisions.
* Collaborate with internal coding, medical review, and provider relations teams to ensure claims are properly coded and supported with documentation.
* Identify coding errors or discrepancies that contributed to claim denials or underpayments.
* **Compliance and Regulatory Oversight:**
* Ensure all appeal responses and claims decisions are in compliance with CMS, state insurance department regulations, and NCQA/URAC standards where applicable.
* Respond to Department of Insurance (DOI) inquiries and external audit requests as needed.
* Maintain documentation and logs of appeal activity for auditing and reporting purposes.
* **Stakeholder Communication:**
* Communicate with providers, members, and internal teams to clarify claim status, appeal outcomes, and required actions.
* Serve as a subject matter expert on coding, claims processing, and policy interpretation for other departments.
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**Required Qualifications:**
* High School Diploma or GED required, Associate or Bachelor’s degree preferred.
* CPC, CCS, RHIT, or other coding certification preferred.
* Minimum 2–4 years of experience in health insurance claims processing, appeals, and coding review.
* Strong knowledge of ICD-10, CPT, HCPCS, and medical billing/coding principles.
* Familiarity with CMS guidelines, ERISA, and managed care policies.
* Excellent analytical and problem-solving skills.
* Strong verbal and written communication abilities.
* Experience with claims processing platforms (e.g., Facets, QNXT, Epic Tapestry) a plus.
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**Work Conditions:**
* Standard office environment or remote/work-from-home setting with proper security and HIPAA compliance.
* Must meet productivity and accuracy benchmarks.
* May require occasional overtime to meet regulatory or internal deadlines.
