Claims Operations Clerk

Job Description

Job Description

POSITION SUMMARY

Solis Health Plans is looking for a Claims Operations Clerk responsible for supporting the Claims Department by reviewing incoming correspondence, managing documentation, and assisting with claims processing in accordance with Plan guidelines. This role requires strong attention to detail, effective communication with providers, and adherence to HIPAA and company standards.

Position is onsite Monday – Friday

DUTIES AND RESPONSIBILITIES

· Review the incoming claim correspondence and determine appropriate next steps.

· Work within SDS (Smart Data Solutions) to review claims for potential rejection and member eligibility.

· Create and assign cases to Claims Specialists as needed.

· Scan, attach, and organize documentation in the system accurately and efficiently.

· Assist with Maximus case preparation in support of Level 2 appeal submissions.

· Provide support with recoupment mailings, ensuring accuracy and timely processing

· Manage and respond to claim-related email inquiries from providers and internal teams.

· Handle G&A faxes and claim faxes for disputes and appeals.

· Process Coordination of Benefits (COB) letters received from members or providers.

· Support overflow work for the claims department and assist with various ad hoc tasks.

· Communicate effectively and professionally with providers regarding claim status and issues.

· Maintain confidentiality and compliance with HIPAA regulations.

QUALIFICATIONS & EDUCATION

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

· Minimum of High School diploma or equivalent.

· 1-3 years’ experience in clerical work and/or within a health plan environment.

· Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations.

· Excellent computer knowledge is required, including proficient knowledge of Microsoft Office.

· Must be self-motivated, organized and have excellent prioritization skills.

· Must be able to work well under stressful conditions.

· Must be able to work in a fast-paced environment.

· Fluency in English and Spanish.

PERFORMANCE MEASUREMENTS

· Duties accomplished at the end of the day/month.

· Attendance/punctuality.

· Compliance with Company regulations.

· Safety and Security.

· Quality of work.

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple, competing tasks and demands and to seek supervisory assistance as appropriate.