Claims Specialist

At TriZetto, we know that a company is nothing without its associates. That’s why we strive to attract and keep the best in the business. To do that, we’ve created a culture that values, rewards, and nurtures the people who make TriZetto run. We offer our associates a number of opportunities to further develop their career, including Associate Professional Development, Leadership Development Program, and TriZetto Academy.

Claims Specialist Processing payments and/or claim denials for complex group health which includes medical, dental, vision, FSA, HSA, HRA and disability benefits and assisting with the set-up of new clients during implementation process and group renewals; demonstrating the highest levels of customer service, technical skills and professionalism to ensure mutually rewarding and continued provider relationships.

• Maintaining external customer relations by interacting with clients regarding claims issues, providing service as key contact for clients and working as directed with the clients vendors, researching and ensuring accurate and complete claim information, contacting insured or other involved parties for additional or missing information and updating claim file information with regard to claims status, questions or claim payments.
• Examining and entering complex claims for appropriateness of care and completeness of information in accordance with accepted coverage guidelines, ensuring all mandated government and state regulations are consistently met.
• Processing complex claims for multiple plans with automated and manual differences in benefits, as well as utilizing the system and written documentation to determine the appropriate payment for a specific benefit.
• Troubleshooting all claims with potential third party liability, i.e. subrogation, COB, or MVA and stop loss claims and potential stop loss files.
• Approving, pending, or denying payment according to the accepted coverage guidelines.
• Assisting in the training of new groups and new staff as needed; assisting the management team in problem resolution, planning and overseeing workflows; testing and preparing documentation and updating current documentation, as well as providing suggestions and recommendations to improve workflows and departmental efficiencies.

• High school diploma, GED Certificate or equivalent.
• Minimum of five years' related experience. Experience with or certification in QicLink preferred. Audit experience preferred.
• Knowledge of medical terminology including CPT-4, ICD-9, ICD-10, HCPCS, ASA and UB92 Codes, and standard of billing guidelines.
• Limited travel.