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Highmark Health Claims Specialist in Home, Pennsylvania

Company :

Allegheny Health Network

Job Description :


This job provides extensive support covering all aspects of billing related claims edits (pre A/R) in an effort to submit clean claims to the third party insurers. Works collaboratively with other departments within the Allegheny Health Network to obtain required information to complete the claim prior to submission.


  • Ensures timely, accurate and efficient processing of claims edits via EPIC work queues. Meets daily claims edit resolutions goals by reviewing, analyzing, and obtaining appropriate documentation based on payer requirements and regulations. Prepares electronic and paper claims and sends with appropriate attachments. Conducts research and provides updates and current status of claims edit work queues using the appropriate data management system (EPIC). Resolves issues that are adversely impacting claims submission in a timely and accurate manner. Completes or requests adjustments to accounts based on dollar threshold. Communicates information and ideas to make system-wide process improvements. Updates patient accounts regarding changes and modifications in plan benefits and other contract information relevant to the claims follow up and collection process. Documents claim processing activity on patient accounts. (20%)

  • Serves as a communication link to various departments and external payers by developing positive relationships with managed care organizations and outside agencies, and clinical areas within the organization. Performs liaison services to both internal and external customers aiding in claims resolution. Assists with education of internal staff and external customers to bring about the timely, accurate, and cost effective adjudication of all claims. Works collaboratively with other departments to facilitate the insurance collections process and to improve overall cash collection. (20%)

  • Monitors the status of claims in work queues and conducts routine, periodic follow up on previously researched claims items. Monitors, reviews, and suggests revisions or updates to existing forms, documents, and processes required to submit a clean claim. (20%)

  • Assists other departments/functional areas as needed with billing, claims, or claims follow up related tasks. (20%)

  • Ensures completeness of claims by following national, local, and internal billing requirements promoting prompt and accurate submission and payment. Maintains awareness of current regulations. Initiates practices that support current regulations. Shares knowledge of current regulations with staff. Analyzes current practices and makes recommendations for process improvements. (20%)

  • Performs other duties as assigned or required.



  • Associate’s Degree or equivalent from a two-year college or technical school; or six months to one year of related experience and/or training; or equivalent combination of education and experience.

  • 1-3 years of previous patient financial services experience in a healthcare environment.

  • Must have knowledge of insurance billing regulations and reimbursement procedures.


  • Previous experience with computerized billing and/or healthcare billing.

  • Familiarity with medical terminology, ICD-9 and CPT-4 coding; third party payors in a healthcare

  • billing environment; and Epic billing module.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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Req ID: J182615