Claims Management - Claims Research Specialist

Virtual Req #695
Thursday, November 18, 2021

Our goals are to provide excellent service, utilize advanced technology, and proficiently deliver results. To accomplish these goals, we constantly seek individuals who look for ways to do things better. We are a company whose culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement.

Tabula Rasa HealthCare (TRHC) is a leader in providing patient-specific, data-driven technology and solutions that enable healthcare organizations to optimize performance to improve patient outcomes, reduce hospitalizations, lower healthcare costs, and manage risk. Medication risk management is TRHC’s lead offering, and its cloud-based software applications, including EireneRx® and MedWise™, provide solutions for a range of payers, providers and other healthcare organizations.


TRHC empowers our employees to provide excellent service, utilize advanced technology, and proficiently deliver results. Our 32Fundamentals are what we are and who we are.  Our culture cultivates teamwork, rewards excellence, focuses on quality for every aspect of our business, and promotes community involvement. As a part of our team, you will help us bring innovative service models to healthcare, improving patient outcomes.

Job Description:                       Claims Research Specialist


Summary:  Under the direction of the Claims Payment Integrity Manager, the Claims Research Specialist is primarily responsible for coordinating the resolution of claims issues by actively researching and analyzing systems and processes that cross multiple operational area and performing analysis of identified claims issues and interpreting results to identify barriers to appropriate claims payment. The Claims Research Specialist also recommends ongoing improvements to processes report outcomes ensuring that claims are selected for payment according to client regulations and client processing rules.  The position leads the problem-solving and coordination efforts among various business units.

Essential functions:

  • Audits check run and send claims to the claims department for corrections
  • Identifies system changes and work with Provider Network and Configuration to implement changes
  • Collaborates with the claims department to price pended claims correctly and automate pends as necessary
  • Documents, tracks and resolves all plan providers claims projects
  • Collaborates with various business units to resolve claims issues to ensure prompt and accurate claims adjudication
  • Identifies authorization issues and trends and research for potential configuration related work process changes
  • Analyzes trends in claims processing issues and assist in identifying and quantifying issues and reviewing work processes
  • Identifies potential and documented eligibility issues and notify applicable departments to resolve
  • Researches the claims on various reports to determine if appropriate to move forward with recovery due to non-covered items being allowed, etc.
  • Runs claims reports regularly through provider information systems
  • Researches verbal and written providers claims inquiries as needed
  • Coordinates with Encounters team to ensure claims processes align with encounter requirements

Additional Functions:

  • Assists with special projects, as requested
  • Communicates clearly and concisely, with sensitivity to the needs of others
  • Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees
  • Maintains courteous, helpful and professional behavior on the job
  • Serves as a champion for the TRHC 32 Fundamentals
  • Establishes and maintains effective working relationships with co-workers
  • Ensures customer satisfaction by understanding and applying the Customer Service Policy, Procedure and Standards
  • Follows all Policies and Procedures and HIPAA regulations
  • Maintains knowledge and understanding of current Medicare regulations related to PACE Health Plan Management.
  • Maintains a safe working environment
  • Maintains knowledge and understanding of current Medicare claims processing guidelines
  • Attends continuing education seminars as requested


Supervisory Responsibility: None


Travel: No travel is anticipated for this position.  


Knowledge, Skills and Abilities:

  • High School Diploma or equivalent required
  • Two years of claims processing or healthcare analytics experience with TPA or Health Plan required
  • Experience working with Managed Care programs strongly preferred (Medicare, Medicaid, LTSS, DSNP, MMP, etc)
  • Experience with provider contracts and contract interpretation strongly preferred
  • Intermediate level of current, demonstratable experience with Microsoft Excel required
  • Skilled in establishing and maintaining effective working relationships with clients, and staff at all levels
  • Skilled in data analysis and problem solving using defined methodologies
  • Ability to work independently with minimal supervision
  • Ability to independently follow through on projects
  • Ability to communicate professionally, clearly and effectively, verbally and in writing
  • Ability to prioritize effectively
  • Ability to consistently multitask
  • Ability to understand issues, demonstrates resourcefulness, and resolve issues in a timely manner
  • Ability to demonstrate good judgment and have excellent critical thinking skills


Physical Demands & Requirements:

  • Communicate by way of the telephone with participants, customers, vendors and staff
  • Operate a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer
  • Remain stationary for extended periods of time
  • Occasionally exert up to 20 pounds of force to lift, carry, push, pull or move objects
  • Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy


Work Environment:

  • This job operates in a professional or home office environment with a conversational noise level.
    • No substantial exposure to adverse environmental conditions is expected.
    • Moderate pressure to meet scheduled appointments and deadlines
    • Potential for occasional verbal aggression by clients and vendors


Supervised By:  Claims Payment Integrity Manager

The Company is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to ancestry or national origin, race or color, religion or creed, age, disability, AIDS/HIV, gender, marital or family status, pregnancy, childbirth or related medical conditions, genetic information, military service, protected caregiver obligations, sexual orientation, protected financial status or other classification protected by applicable law.

Other details

  • Pay Type Hourly
  • Telecommute % 100