Claims Specialist (Healthcare)

The Claims Specialist is responsible for the submission, tracking, and reconciliation of healthcare claims through managed care organizations. This role is not client-facing but works closely with internal teams, requiring clear communication to ensure claims are submitted accurately, tracked effectively, and approved and reimbursed in full.

The goal of this role is to achieve a 100% clean claim and reimbursement rate, supporting revenue integrity and operational efficiency.

Key Responsibilities

• Submit healthcare claims through Availity or United Healthcare Portal to managed care organizations (MCOs)

• Monitor and track claim status from submission through reimbursement

• Identify and resolve claim rejections, denials, or errors

• Coordinate with internal teams to ensure claim accuracy and completeness

• Maintain detailed records of claims activity and outcomes

• Support internal audits and compliance checks related to claims processing

• Ensure all claims meet payer and regulatory requirements

Required Skills & Qualifications

• Experience in healthcare claims processing (required)

• Prior experience using Availity (required)

• Strong attention to detail and administrative accuracy

• Comfortable working with healthcare data and financial records

• Ability to manage high-volume, repetitive workflows

• Organized and process-driven mindset

Tools & Systems

• Availity - required experience

• United Healthcare Portal – experience strongly preferred

• Google Workspace (G Suite) – trainable

• HMIS – trainable

• Internal billing and documentation systems