CLAIMS REVIEW SPECIALIST

State of Arkansas•Little Rock, AR

About The Position

The function of this position requires flexibility with ever-changing priorities and administrative directives. The Claims Review Specialist works under general supervision and is responsible for providing clerical and technical support to supervisory, medical, and other professional Utilization Review staff. Significant functions of this position include assisting with Medicaid Provider & Beneficiary Appeal Requests and administrative duties related to UR audits. Position utilizes specialized programs including, but not limited to, MMIS Interchange, SharePoint, Adobe, Word, Docushare, and Excel. This position is governed by state and federal laws and agency policy. The Claims Review Specialist plays a critical role in supporting the insurance claims process by reviewing and evaluating claims for accuracy, completeness, and compliance with pre-determined agency policies and regulatory standards. This classification involves verifying claim documentation, investigating discrepancies, and ensuring the timely and efficient resolution of claims.

Requirements

High school diploma or GED.
Two years of experience in clerical or administrative functions.
Strong analytical and problem-solving skills, attention to detail, good written and verbal communication.
Willingness to learn and adapt to new tools, technologies, and processes.
Experience with using standard office software (e.g., Microsoft Excel, Word).
A proactive and team-oriented approach to work.
Familiarity with department related programs.

Nice To Haves

Communication skills-as this is a help desk and call center for members and providers.
Preferable pharmacy technician experience including knowledge of Medicaid.
If no pharmacy technician experience, preferable to have knowledge of DHS/DMS programs to assist with pharmacy help center calls.
Experience/proficiency with Excel
History of auditing or oversight on projects

Responsibilities

Assess insurance claims to ensure all required information is accurate and complete.
Verify claim documentation against policy terms and conditions.
Identify missing or inconsistent information and coordinate with the appropriate personnel to resolve issues.
Document findings and actions taken for each claim in an organized manner.
Communicate claim outcomes and provide necessary explanations to policyholders or internal personnel.
Support fraud detection and prevention efforts by reporting unusual patterns or inconsistencies.
Stay informed on agency policies, industry practices, and relevant regulations.
Collaborate with senior team members and managers to improve claims processing workflows.