Top 58 Claims specialist Jobs in Smithfield Ri

Case Specialist - GAU
Blue Cross and Blue Shield of RI Careers —Providence, RI
- $53,400 - $72,000 a year
- Full-time
- Hybrid work
- Inventory management
- Data analysis skills
- HIPAA
- Loan repayment program
- Dental insurance
10h
Customer Service Specialist
Brown University Health —Providence, RI
- $20.96 - $34.61 an hour
- 8 hour shift
- Research
- Office
- High school diploma or GED
14d
Third Party Specialist
Care New England Health System —Warwick, RI
- $19.05 - $32.75 an hour
- Full-time
- Word processing
- Mid-level
- High school diploma or GED
Insurance Benefit Specialist
Highbar Physical Therapy —Providence, RI
- From $20 an hour
- Full-time
- High school diploma or GED
- Entry level
- Wellness program
- Paid holidays
Quick Apply
MG Patient Service Specialist
Brown University Health —Providence, RI
- $18.13 - $29.90 an hour
- 8 hour shift
- Microsoft Excel
- Microsoft Outlook
- High school diploma or GED
Total Rewards Specialist, Benefits
Pet Food Experts,LLC —Pawtucket, RI
- $70,000 - $85,000 a year
- Background check
- Google Workspace
- HIPAA
- Paid parental leave
- Health savings account
Quick Apply
Quality Assurance Specialist
Hagen Group —Mansfield, MA
- $70,000 - $80,000 a year
- Full-time
- Hybrid work
- Salesforce
- Mid-level
- Office
Quick Apply
4d
Medical Billing Specialist - FULL TIME - Framingham -At least 2 yr exp required
Complete Pain Care —Framingham, MA
- $24 - $32 an hour
- Online Application
- Spanish
- Mid-level
- High school diploma or GED
- Health insurance
- Dental insurance
Quick Apply
15h
Sr. Collections Specialist
North Easton Savings Bank —South Easton, MA
- $23.00 - $30.50 an hour
- Full-time
- Hybrid work
- Bilingual
- Writing skills
- Mid-level
6d
Billing Specialist
Care New England Health System —Warwick, RI
- Full-time
- Word processing
- English
- Mid-level
Medical Billing Specialist
Comprehensive Community Action —Warwick, RI
- $21 - $25 an hour
- Full-time
- Spanish
- Microsoft Outlook
- Computer literacy
- Paid holidays
- Health insurance
Quick Apply
TPA Claims Specialist II
USI Holdings Corporation —Warwick, RI
- $57,000 - $77,000 a year
- 5 years
- High school diploma or GED
- Analysis skills
- Wellness program
- Health savings account
Sr. Litigation Specialist -Remote
CSAA Insurance Services, Inc. —Pawtucket, RI
- $89,865 - $119,800 a year
- Extended hours
- Remote
- Bilingual
- Bachelor of Science
- High school diploma or GED
- 401(k) matching
Referral & Authorization Specialist
Care New England Health System —Warwick, RI
- Full-time
- Bilingual
- Customer service
- HIPAA
2h
Insurance Authorization Specialist
Highbar Physical Therapy —Providence, RI
- From $20 an hour
- Full-time
- High school diploma or GED
- Front desk
- Outpatient
- Wellness program
- Paid holidays
Quick Apply
Medical Billing Professional Cardiology Denial Specialist
Brown University Health —Providence, RI
- $19.97 - $32.96 an hour
- 8 hour shift
- HIPAA
- Mid-level
- Office
14d
Medical Billing Specialist
Accurate Billing Solutions LLC —Warwick, RI
- $25 - $27 an hour
- Part-time
- 5 years
- Office
- In-person
- Paid time off
- Flexible schedule
Quick Apply
Authorization Specialist/Biller
Care New England Health System —Warwick, RI
- Full-time
- English
- Research
- Mid-level
Professional Biller II
Care New England Health System —Warwick, RI
- Full-time
- Mid-level
- 3 years
- Math
Patient Service Specialist
Brown University Health —Foxborough, MA
- $18.13 - $29.90 an hour
- 8 hour shift
- Microsoft Excel
- Microsoft Outlook
- High school diploma or GED

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Case Specialist - GAU

Blue Cross and Blue Shield of RI Careers -
Providence, RI

Apply Now

Job Details

Full-time
$53,400 - $72,000 a year
10 hours ago

Benefits

Loan repayment program
Dental insurance
Tuition reimbursement
Paid time off
Vision insurance

Qualifications

Research

Full Job Description

Pay Range:

$53,400.00 - $72,000.00

Please email [email protected] if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI, our greatest resource is our people.

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well.

We recognize that to do your best work, you have to be your best self.
It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders.

We’re dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Why this job matters:

The GAU Case Specialist is responsible for investigating, managing, and resolving member and provider grievances, complaints, and appeals in accordance with organizational policies, regulatory requirements, and service-level agreements. This position performs detailed research, analyzes information from multiple sources, documents findings, prepares written determinations, and ensures all cases are processed accurately, timely, and in compliance with CMS, NCQA, state, and internal requirements.

What you will do:

Manage a caseload of grievances, complaints, and appeals from receipt through final resolution.
Review and analyze case documentation, claims information, benefit plans, policies, contracts, and supporting records.
Conduct thorough investigations to determine the appropriate outcome for each case.
Document all case activity, research, and determinations in designated systems.
Ensure compliance with all regulatory and internal timeliness requirements.
Monitor assigned inventory and proactively communicate potential barriers to timely completion.

Research and Analysis

Research member, provider, and claim issues utilizing multiple systems and data sources.
Collaborate with internal departments, clinical staff, business partners, and external vendors as needed to obtain information required for case resolution.
Analyze contract language, medical policies, benefit plans, and regulatory guidance to support case determinations.
Identify trends, process gaps, and opportunities for operational improvements.

Documentation and Regulatory Compliance

Maintain complete, accurate, and audit-ready case documentation.
Ensure all required fields, regulatory categories, and reporting elements are accurately completed.
Adhere to CMS, NCQA, HIPAA, state regulatory, and organizational requirements.
Support internal and external audit activities as requested.
Follow established departmental workflows, policies, and procedures.

Communication and Correspondence

Draft and generate acknowledgment and determination letters.
Communicate professionally with members, providers, delegates, and internal stakeholders.
Participate in meetings, huddles, training sessions, and calibration activities.
Provide clear and concise explanations regarding case findings and determinations when appropriate.

Quality and Performance

Meet established productivity, quality, and timeliness standards.
Maintain satisfactory quality review scores and documentation accuracy.
Demonstrate accountability for assigned work and performance goals.
Participate in continuous improvement initiatives and process enhancement efforts.
Assist with cross-training and departmental projects as assigned.

Success in this role is measured by

Case timeliness and SLA compliance.
Quality audit results.
Documentation accuracy and completeness.
Productivity and inventory management.
Regulatory compliance.
Collaboration and professional communication.

What you need to succeed:

Strong analytical and critical-thinking skills.
Excellent written and verbal communication skills.
Ability to interpret regulatory requirements, policies, and benefit plans.
Strong organizational and time-management skills.
Ability to manage multiple priorities in a deadline-driven environment.
Attention to detail with a focus on accuracy and compliance.
Proficiency using Microsoft Office applications and case management systems.
Ability to work independently and collaboratively within a team environment.
Two or more years of relevant experience either administrative or with the company in another department with relevant knowledge.
Experience in healthcare operations, claims, customer service, grievances, appeals, complaints, utilization management, or related healthcare functions preferred.
Knowledge of Medicare, Commercial Health Insurance, CMS, NCQA, and regulatory requirements preferred.

The extras:

Bachelor's degree preferred in Healthcare Administration, Business Administration, or a related field; equivalent combination of education and relevant experience may be considered.

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

In-office : onsite 5 days per week
Hybrid: onsite 2-4 days per week
Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer.

The law requires an employer to post notices describing the Federal laws. Please visit www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.

Apply Now

Refine Your Search

claims specialist jobs in smithfield ri

Case Specialist - GAU

Customer Service Specialist

Third Party Specialist

Insurance Benefit Specialist

MG Patient Service Specialist

Total Rewards Specialist, Benefits

Quality Assurance Specialist

Medical Billing Specialist - FULL TIME - Framingham -At least 2 yr exp required

Sr. Collections Specialist

Billing Specialist

Medical Billing Specialist

TPA Claims Specialist II

Sr. Litigation Specialist -Remote

Referral & Authorization Specialist

Insurance Authorization Specialist

Medical Billing Professional Cardiology Denial Specialist

Medical Billing Specialist

Authorization Specialist/Biller

Professional Biller II

Patient Service Specialist

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Why this job matters:

Research and Analysis

Documentation and Regulatory Compliance

Communication and Correspondence

Quality and Performance

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