Claims Specialist

A client of Innova Solutions is immediately hiring a Claims Specialist Position type: Contract to HireLocation: 2401 White Plains Road Bronx New York 10467 United StatesSchedule: 40-hour work weeksShift:  Mon-Fri from 8:30 a.m.-5:30 p.m. (with 1-hour lunch)Minimum of 2 days will be worked onsite (usually Wednesday and Friday), though this may vary.   As a Claims Specialist, you will:The Claims Specialist will support department operations related to provider communication, pended claim review, reporting, auditing, and oversight activities to ensure compliance with all applicable State, Federal, and contractual guidelines.RESPONSIBILITYThe Claims Specialist will be responsible for reviewing claims processed by the outside vendor, including resolving provider appeals/disputes. Performs root cause analysis for all provider projects to identify areas for provider education and/or system (re)configuration. Initiates and follows through with resolution of all pended claims, (re)pricing, returned or refund checks and the development of provider and facility compensation grids. Provides feedback or suggestions to enhance current processes or systems.Reviews and investigates claims to be adjudicated by the TPA, including the application of contractual provisions in accordance with provider contracts and authorizationsCompiles claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely mannerInvestigates suspense conditions to determine if the system or procedural changes would enhance claim workflowCommunicates and follows up with a variety of internal and external sources, including but not limited to providers, members, attorneys, regulatory agencies, and other carriers on any claim related mattersAnalyzes patient and medical information to identify COB, Worker's Compensation, No-Fault, and Subrogation conditionsValidates DRG grouping and (re)pricing outcomes presented by the claims processing vendorAttends JOC meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelinesAssists TPA with provider compensation configuration by creating and testing compensation grids used for reimbursement and claims processingEnsures that refund checks are logged and processed, enabling expedited credit of monies returnedAnalyzes check return/refunds volumes and trends to determine root causes. Proposes workflow changes to correct and enhance claim processes to prevent returned checks/refundsGenerates routine daily, monthly and quarterly reports used for managing process timeframes and vendor productivity, ensuring compliance with all regulatory requirements and contractual vendor SLAsParticipates in special projects and performs other duties as assigned Meet a standardized set of competencies for the specific position description established by the organization before working independently.Acting member of the IDT.All other duties as assigned. The ideal candidate will have: Education: Bachelor's degree.  Certified Professional Coder (a plus)Experience:Eight or more years of insurance experience within a healthcare or managed care setting (preferred)Claims adjudication experienceKnowledge of MLTC/ Medicaid/Medicaid benefitKnowledge of Member (Subscriber) enrollment & billingKnowledge of Utilization AuthorizationsKnowledge of Provider ContractingKnowledge of CPTs, ICD 9/ICD 10, HCPC, DRG, Revenue, RBRVSProficiency in MS Excel, Word, PowerPoint, and experience using a claims processing system or comparable database software Qualified candidates should APPLY NOW for immediate consideration!  Please hit APPLY to provide the required information, and we will be back in touch as soon as possible.We are currently interviewing to fill this and other similar positions. If this role is not a fit for you, we do offer a referral bonus program for referrals that we successfully place with our clients, subject to program guidelines.   ASK ME HOW.Thank you! Jyoti Tiwari678-496-7813 Jyoti.Tiwari2@ PAY RANGE AND BENEFITS:Pay Range*: $20/hr - $25/hr*Pay range offered to a successful candidate will be based on several factors, including the candidate's education, work experience, work location, specific job duties, certifications, etc. Benefits: Innova Solutions offers benefits( based on eligibility) that include the following: Medical & pharmacy coverage, Dental/vision insurance, 401(k), Health saving account (HSA) and Flexible spending account (FSA), Life Insurance, Pet Insurance, Short term and Long term Disability, Accident & Critical illness coverage, Pre-paid legal & ID theft protection, Sick time, and other types of paid leaves (as required by law), Employee Assistance Program (EAP). ABOUT INNOVA SOLUTIONS: Founded in 1998 and headquartered in Atlanta, Georgia, Innova Solutions employs approximately 50,000 professionals worldwide and reports an annual revenue approaching $3 Billion. Through our global delivery centers across North America, Asia, and Europe, we deliver strategic technology and business transformation solutions to our clients, enabling them to operate as leaders within their fields. Recent Recognitions: Named One of America’s Best Employers for New Grads by Forbes (2024Named One of the Best Companies to Work for by U.S. News & World Report (Private Companies List, 2024-2025)One of the Largest IT Staffing Firms in the US – Ranked #3 by Staffing Industry Analysts (SIA, 2024)One of the Largest Staffing Firms in the US – Ranked #13 by Staffing Industry Analysts (SIA, 2024; includes Innova Solutions, Volt, & HireGenics)Named One of the Top Ten Private Companies in Atlanta by the Atlanta Business Chronicle (2023)One of the Largest Certified Minority Business Enterprises (MBEs) in the United States (NMSDC, 2024)AWS Advanced Tier Services Partner with 100+ certifications Website: Solutions is an Equal Opportunity Employer and prohibits any kind of unlawful discrimination and harassment. Innova Solutions is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment on the basis of race, color, religion or belief, national origin, citizenship, social or ethnic origin, sex, age, physical or mental disability, veteran status, marital status, domestic partner status, sexual orientation, or any other status protected by the statutes, rules, and regulations in the locations where it operates.  If you are an individual with a disability and need a reasonable accommodation to assist with your job search or application for employment, please contact us at hr@ or (770) 493-5588. Please indicate the specifics of the assistance needed.  Innova Solutions encourages all interested and qualified candidates to apply for employment opportunities.   Innova Solutions (HireGenics/Volt) does not discriminate against applicants based on citizenship status, immigration status, or national origin, in accordance with 8 U.S.C. § 1324b.The company will consider for employment qualified applicants with arrest and conviction records in a manner that complies with the San Francisco Fair Chance Ordinance, the Los Angeles Fair Chance Initiative for Hiring Ordinance, and other applicable laws. INDGN01  

Created: 2025-06-03