The Claims Specialist reports to the Claims Department Manager in the MWG-Administrators TPA Division. The position is a non-exempt, hourly role and is located at 75 Valencia Avenue, Coral Gables, FL 33134.

GENERAL JOB DUTIES AND RESPONSIBILITIES:

The Claims Specialist will review claims for reporting information in a spreadsheet or software and communicate with the TPA Manager and Claims Manager daily as well as possibly interacting with groups, claimants, outside carriers, and agents. To perform the job successfully, the employee must be able to perform each essential duty satisfactorily. The requirements listed here are representative of the knowledge, skill, and ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Perform review and adjudication of insurance claims.
• Utilize MWG Administrators Policy Administration System and Claims Management Software to verify eligibility and review member accounts based on the policy assigned.
• Input data into MWG Administrators Claims Management Software.
• Handle incoming mail, provider appeals, inquiries, and racers.
• Review member correspondence and process or direct to the appropriate department.
• Maintain quality customer service by following customer service best practices and being responsive.
• Perform periodic audits on individual and group policies to verify claims have been paid correctly.
• Protect operations by keeping claims information confidential.
• Ensure legal compliance by following company policies, procedures, and guidelines.
• Identify escalated issues and handoff to supervisor.
• Meet or exceed all performance metrics.
• Be knowledgeable and have a clear understanding of the business processes within MWG including internal departments, insurance carriers, brokers/agents, and group contacts.
• Utilize MWG Administrators Policy Administration System and Claims Management Software to verify eligibility and review member accounts based on the policy assigned.
• Perform other duties as assigned by the Department Manager.

EXPERIENCE AND EDUCATION REQUIREMENTS:

• High School Diploma or GED required; Associates or bachelor's degree is preferred.
• Must have 1-2 years of previous insurance claims experience; previous experience with electronic
• data interchange (EDI) of files is preferred.
• Must have excellent computer skills and be knowledgeable in MS Outlook, Windows, Excel, and Word.
• Must be able to learn and be proficient with the software used in the TPA department.
• Must possess strong time management, organizational, problem solving, and customer service skills.
• Must be able to work well under pressure with multiple priorities and meet deadlines while maintaining attention to details.

WORKING ENVIRONMENT:

• Must be able to perform in a very high paced environment while multi-tasking or handling interruptions.
• Must have the ability to work independently while practicing effective time management skills.
• Must be able to prioritize projects, work multiple projects simultaneously, and meet project deadlines in an organized manner.
• Must possess excellent problem-solving skills and have keen attention to details.
• Strong written and verbal communication, interpersonal, and relationship building skills are required.
• Must be able to handle stressful situations appropriately.

JOB ESSENTIAL REQUIREMENTS:

The following are job functions that an employee must be capable of performing with or without reasonable accommodation.

• Must be able to read, write, and speak English; Spanish is a plus.
• Must be able to work as scheduled.
• Must possess sight and hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of the position as stated above can be fully met.
• Must be able to bend, stretch, reach, and sit or stand at a desk during 85% of the workday.
• Must be able to lift, stoop, and carry small equipment items and supplies, possibly weighing up to 20lbs.

REASONABLE ACCOMODATIONS:

Morgan White Group will reasonably accommodate qualified individuals with a disability so that they can perform the essential functions of a job, unless doing so causes a direct threat to these individuals or others in the workplace and the threat cannot be eliminated by reasonable accommodation or if the accommodation creates an undue hardship to Morgan White Group.

EQUAL OPPORTUNITY EMPLOYER:

MWG is an Equal Opportunity Employer, committed to the principles of the EEOC. All employment decisions are based upon each person's qualifications, abilities, and performance. Our company works to provide an environment where human dignity prevails and all employees and applicants for employment receive equal consideration and fair treatment, without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.