Policy Support Specialist

Job Summary

Responsible for reviewing medical policies and preparing cases for clinical review, the full-time Policy Support Specialist will track additional information requests to ensure end-to-end resolution of clinical claims and service inquiries while working remotely.

Key responsibilities

• Research member medical records to resolve claims or service requests pending clinical edits
• Review medical policies to determine claim processing and clinical review decisions
• Coordinate clinical review and appeal processes, including preparing cases and requesting additional information

Required qualifications

• Minimum of a High School Diploma or GED equivalent
• Three (3) years of health care claims processing experience
• Two (2) years of experience with medical terminology, billing, and coding
• Knowledge of Coordination of Benefit (COB) and medical policies preferred
• Familiarity with all lines of business preferred