Claims Specialist II

Pay Plan

Title:

Claims Specialist II

Working Title: Claims Specialist II

FLSA Status: Non-Exempt

Posting Salary Range: $42,765 - $61,546

Office

Location:

Remote within North Carolina

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.

Trillium believes that empowering others begins with supporting our team. We offer our employees:

• A collaborative, mission-driven work environment
• Competitive benefits and work-from-home options for most positions
• Opportunities for professional growth in a diverse inclusive culture

Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.

Trillium Health Resources has a career opening for a Claims Specialist II to join our team! The Claims Specialist II performs data analysis, auditing and finalizes adjudication results for claims designated for pre-payment review and post payment review of claim adjudication results through research and knowledge of billing guidelines and policies established by CMS, and NC Medicaid as well as Trillium policies and procedures.

This position is also responsible for assisting providers by phone or email with claims processing questions as well as communicating with internal and external stakeholders to facilitate efficient claims resolution.

• Analyze and audit claims adjudication results to determine if claims were accurately submitted and processed according to NC Medicaid guidelines.
• Analyze and audit claim attachments/medical documentation necessary to appropriately adjudicate a claim.
• Analyze, audit and take appropriate actions for claims delayed for adjudication due to rejection errors.
• Identify adjudication errors, provider billing errors, and the need for technical assistance.
• Ensure the claims system and manual processes are incorporating required actions by reviewing and applying information from departmental trainings, published coverage policies and other NCDHHS documents.
• Provide training, education and technical assistance to provider agencies based on analysis or audit findings related to basic claim submission guidelines, denial management, system use and updates.
• Recognize and report suspected system issues or concerns to immediate supervisor for follow-up based on data analysis.

Trillium knows that work/life balance is essential. That’s why we offer:

• Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval.
• Work-from-home options available for most positions
• Health Insurance with no premium for employee coverage
• Flexible Spending Accounts
• 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year
• NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook
• 401k with 5% employer match and immediate vesting
• Public Service Loan Forgiveness (PSLF) qualifying employer
• Quarterly stipend for remote work supplies

• High School Diploma/GED and two (2) years of experience in claims processing, billing, or medical coding; OR
• Equivalent combination of education/experience.
• Must have a valid driver’s license
• Must reside within North Carolina
• Must be able to travel within catchment…