Claims Specialists

Job Description:

Claims Specialists are responsible for properly reviewing and processing claims for Flexible Spending Accounts and Health Reimbursement Arrangements according to IRS regulations and specific employer plan rules.

Claims are received via a variety of methods including the consumer portal, mobile application, emails, faxes and mail.
All claims have keywords assigned to them before they flow into the Claims workflow queues in OnBase.

Uploaded documentation via the consumer portal and the mobile application have the keywords and claim types assigned automatically by the OnBase platform, and they will include a claim number that will be used when processing the claim.

Non-uploaded claims (emails, faxes and mail) have keywords assigned by the Mail team during the indexing process. The assigned keywords on each of the documents are key to ensuring the appropriate routing of the document within the OnBase lifecycle.

Once the claims are in the appropriate queue within the lifecycle, the Claims Specialists will review the documentation received in OnBase while also pulling up the claim in the Health Cloud platform by either copying and pasting the claim number or by keying in the SSN and finding the applicable claim.

In Health Cloud, the Claims Specialists review a few key pieces of information such as the plan name, plan year and amount of the claim.

This information is necessary when reviewing the documentation received in OnBase. From there, the Claims Specialists review the documentation in OnBase for the date of service, type of service and dollar amount charged.

They will determine if the expense is eligible under the plan and plan year the claim is filed to as well as if there are enough eligible charges to approve the claim.

Claims Specialists can either approve or deny a claim in the Health Cloud platform depending on the determination made by the Claims Specialist.

Once the claim is updated in the Health Cloud platform, it's submitted, and the claim is then completed in the OnBase workflow queue.
Once the claim is completed in OnBase, the next claim is automatically made available to the Claims Specialist to repeat the process.

Claims Specialists spend their entire day working through the automatically fed claims queues within OnBase in the designated order to ensure turnaround times are met for our clients. Claims need to be processed within two business days.