Claims Specialist

Being on medication is tough enough. We want to make getting it the easy part. Getting prescriptions to patients has become increasingly complex. When things get messy along the prescription journey, pharmaceutical manufacturers rely on us to untangle the process and create a clear path—allowing patients to build trusting relationships with their medication brands.

We’re not only committed to taking the pain out of the prescription process, but we’re also devoted to bringing the brightest minds together under one roof. We bring together diverse voices—engineers, pharmacists, customer service veterans, developers, program strategists and more—all with one vision. Each perspective and experience makes ConnectiveRx better than the sum of its parts.

The Claims Specialist, under the direction of the Supervisor (with guidance from a Team Lead), is responsible for processing medical claims received from patients and/or HCPs across a broad product suite.  An individual in this role is expected to meet or exceed productivity and quality standards.  Associates possess a solid understanding of department processes, products, and operational tools/systems.  This position utilizes ConnectiveRx and 3rd party systems to process claims and respond to inquiries from patients, physicians, pharmacies, and clients.  The Associate may be assigned additional responsibilities by the Supervisor.

• →Verifies the accuracy and completeness of claim forms and attachments, such as EOBs, EOPs, SPPs, and pharmacy receipts.  Information is entered into adjudication systems as required.  Claims are paid or rejected based upon system adjudication and/or application of business rules external to the systems.  Consult with the Team Lead or Supervisor for complex claims or clarification of business rules.  Obtains missing information by calling or writing customers using standard scripts or form letters.  Based on volume, may also process claims and/or answer phones
• →Refers to requests for escalation as needed and engages other internal areas such as Program Management, IT, and other Contact Center teams to resolve issues.   
• →Provide input and feedback to the Supervisor, Quality Management, and Training (among others) to improve processes, procedures, and training.  
• →Other projects and tasks as assigned

• High School or GED required 
• 1+ years in a health care or case management setting
• Experience working in pharmacy benefits, health care insurance, and/or medical billing a must
• Health care or pharmaceutical experience, particularly in a medical claims processing, billing provider, or insurance environment 
• Knowledge of EOB and EOP statements
• Prior experience in a high-volume processing setting (i.e., doctor’s office, claims processing department, etc.) a plus.
• Will be trained to support programs, clients, and/or job functions as appropriate
• Experience with Third-Party systems (SelectRx, Pro-Care, FSV) (preferred)
• Fluent in English/Spanish (a plus).
• Knowledge of Medical Claims processing/billing coding
• Communication skills: Uses writing effectively to create documents, uses correct spelling, grammar, and punctuation; Ability to convey written and verbal information in easy-to-understand language.
• Customer Focus: High level of empathy and emotional intelligence; Focuses on the opportunity to service patients with a high level of empathy
• Detail Oriented: Achieves thoroughness and accuracy when accomplishing a task
• Adaptability: Adapts to a variety of situations easily and effectively navigates situations
• Problem Solve; Thinks critically, and problem-solves issues to resolution

Compensation & Benefits:  Compensation for this role varies based on factors such as location, relevant skills, experience, and capabilities.   

Employees at ConnectiveRx can enroll in comprehensive benefit plans, including medical, dental, vision, life, and disability insurance. The company retains the right to update or modify health, welfare, and other fringe benefit policies. Employees may also participate in the company's 401(k) plan.   

Time-Off & Holidays:  ConnectiveRx provides paid time off (PTO) to non-exempt employees for vacations and personal leave. For sick leave, eligible non-exempt employees receive Sick Time Off (STO) in accordance with company policy. PTO and STO are prorated during the first year of service. Employees also receive eight standard company holidays and three floating holidays annually, with floating holidays prorated in the first year.   

The company is committed to maintaining competitive benefits and reserves the right to adjust employee offerings, including PTO, STO, and holiday policies, in compliance with applicable laws and regulations.