Job Summary
The Claims Processor is responsible for reviewing, processing, and resolving insurance claims related to behavioral health and mental health services. This position ensures claims are accurate, compliant with payer guidelines, and submitted and adjudicated in a timely manner. The Claims Processor works closely with clinical staff, billing specialists, insurance companies, and clients to resolve claim issues, maximize reimbursement, and support the agency's revenue cycle while maintaining compliance with HIPAA and other applicable regulations.
Essential Duties and Responsibilities
- Verify insurance eligibility, benefits, authorizations, and coverage requirements.
- Analyze denied, rejected, or underpaid claims and take appropriate corrective action.
- Communicate with insurance carriers regarding claim status, appeals, and payment discrepancies.
- Prepare and submit appeals with supporting clinical documentation when appropriate.
- Work collaboratively with billing, intake, clinical, and administrative staff to resolve claim-related issues.
- Ensure claims are submitted accurately and within payer filing deadlines.
- Maintain detailed documentation of claim activity and communications.
- Monitor payer policies and regulatory changes affecting behavioral health reimbursement.
- Identify trends in claim denials and recommend process improvements.
- Assist with audits and ensure compliance with federal, state, and payer regulations, including HIPAA.
- Provide excellent customer service to clients regarding insurance and claim-related questions when needed.
- Other related duties
Qualifications
- Certified Professional Coder (CPC) or Certified Billing and Coding Specialist (CBCS).
- Specialized training in behavioral health coding preferred.
- Minimum of 2 years of experience in medical/behavioral health claims processing, insurance claims adjustment.
- Knowledge of behavioral health insurance CPT, ICD-10, and HCPCS coding principles.
- Experience working with commercial insurance, Medicaid, Medicare, and managed care organizations.
- Familiarity with electronic health records (EHR) and medical billing software.
- Strong understanding of HIPAA privacy and security requirements.
- Bilingual / Spanish preferred.
Knowledge, Skills, and Abilities
- Strong analytical and problem-solving skills.
- Excellent attention to detail and organizational abilities.
- Effective written and verbal communication skills.
- Ability to interpret insurance policies, payer guidelines, and explanation of benefits (EOBs).
- Proficiency with Microsoft Office and claims management systems.
- Ability to prioritize multiple tasks and meet deadlines in a fast-paced environment.
- Strong customer service and interpersonal skills.
- Ability to maintain confidentiality and professionalism when handling sensitive client information.
Working Conditions
- Office, hybrid, or remote work environment based on agency needs.
- Primarily sedentary work involving prolonged computer use.
- Occasional interaction with clients, insurance representatives, and clinical staff.
Physical Requirements
- Ability to sit for extended periods.
- Frequent use of a computer, telephone, and standard office equipment.
Reports To
Office Manager, Billing Manager, or Director of Operations (as assigned).
Pay: $18.00 per hour
Application Question(s):
- Do you have specialized training in behavioral health claims processing?
Experience:
- medical/behavioral health claims processing: 2 years (Required)
Language:
- both English and Spanish (Preferred)
License/Certification:
- CPC or CBCS certification (Required)
Shift availability:
Ability to Commute:
- Clermont, FL 34714 (Required)
Work Location: Hybrid remote in Clermont, FL 34714
