
Clinical Claims Specialist
4 days ago
Clinical Investigator
We are seeking an experienced and skilled Clinical Investigator to join our team. This role involves investigating, recovering, and resolving all types of claims, as well as recovery and resolution for health plans, commercial customers, and government entities.
- Key Responsibilities:
- Initiating telephone calls to gather coordination of benefits data from members, providers, and other insurance companies.
- Investigating and pursuing recoveries and payables on subrogation claims and filing management.
- Processing recovery on claims, ensuring adherence to state and federal compliance policies, reimbursement policies, and contract compliance.
- Conducting contestable investigations to review medical history, monitoring large claims including transplant cases.
- Preventing the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT diagnosis codes, CMC guidelines, along with referring to client-specific guidelines and member policies.
- Adhering to state and federal compliance policies and contract compliance.
- Assisting the prospective team with special projects and reporting.
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