Medical Claims Specialist

Company Overview

NTT DATA strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward‑thinking organization, apply now. We are currently seeking a Claims Specialist to join our team in Baton Rouge, Louisiana (US-LA), United States (US).

Claims Specialist

The claims Specialist will identify primary vs. secondary coverage when a member has more than one health plan. Reviewing and updating claims to reflect correct COB rules. Applying COB primacy rules (subscriber status, effective dates, plan type, Medicare coordination, etc.). Communicating with members, providers, and other insurers to verify coverage details. Correcting over payments, initiating refunds or reprocessing, and maintaining accurate claim records.

Working within claims systems and following regulatory and compliance requirements (e.g., HIPAA).

• Duties may include the following responsibilities or functions required to support the claims unit.
• Reviews, research, and make necessary updates to claims that may include the following: recalculation of benefits to previously processed claims, the processing of claims edits, or initiation of refund requests, according to contractual benefits or provider reimbursement rules, ultimately providing a high degree of customer satisfaction.
• Achieves and maintains a clear understanding of all systems, applications, and procedures necessary to identify denial codes, edits, and processing codes pertaining to all claims (including our coordination with additional coverage plans) to process both coordinated and non‑coordinated claims correctly. Requesting medical records may be required.
• Communicates, both orally and in writing, with internal and external contacts to provide necessary and accurate information for the establishment of sound claims records. This may include, but is not limited to, the coordination of benefits (COB), medical record requests, etc.
• Review quality audits for correction or routing within 48 hours of receipt following departmental and corporate guidelines to ensure accuracy of claims processing and customer satisfaction.
• Research, investigates, and determines the correct order of benefits for payment to be made by the applicable plans and makes necessary corrections to COB records. Communicates to appropriate department(s) when Medicare has determined primacy incorrectly and ensures a letter is generated to notify Medicare. Failure to report discrepancy could result in a daily fine up to ***.
• Analyzes, investigates, resolves problem cases (including COB records, adjusting previously processed claims and requesting refund of overpaid claims). Reviews of all previously processed claims to ensure consistency in payments to maximize recovery of over payments following corporate and departmental guidelines to ensure financial stability.
• Executes procedures to recover funds from providers, subscribers, or beneficiaries where over payments have occurred to ensure accuracy of claims processing and financial stability.
• Provides support as needed (i.e., training, implementations, and documentation). May complete special projects as assigned by Management due to internal audit findings, multiple provider status changes, and system errors following corporate and departmental guidelines to ensure financial stability and customer satisfaction.

• 2+ years in medical claims processing required
• Coordination of Benefits (COB) processing experience preferred

• Strong analytical ability, that includes strong logical, systemic, and investigative thinking.
• Strong oral and written communication skills and human relations skills are necessary.
• Working knowledge of relevant PC software.
• Ability to prioritize multiple streams of work effectively.

High School Diploma or equivalent required.

Where required by law, NTT DATA provides a reasonable range of compensation for specific roles. The starting pay range for this remote role is $18-$19.25/hour. This range reflects the minimum and maximum target compensation for the position across all…