Join the VitalCore Team in Massachusetts! We're people who are fueled by passion, not by profit.
VitalCore Health Strategies (VCHS), an industry leader in Correctional Healthcare, has an opening for a Full-Time Utilization Management Claims Specialist at the Regional Office in Hopkinton, MA!
At VitalCore, we pride ourselves on retaining and acquiring hardworking and ethical individuals committed to providing quality services. Join our team and experience first-hand how VitalCore Health Strategies promotes a positive work environment based on respect and appreciation for our staff's dedication.
The Utilization Management Claims Specialist is responsible for reviewing and evaluating off-site healthcare service claims for accuracy, completeness, and compliance with organizational and contractual policies and regulatory guidelines.
This role ensures accurate flow of medical information between patients, external providers, and third-party payers; researches and analyzes data to support reimbursement processes; identifies potential billing errors, duplicates, fraud, waste, or abuse; conducts preliminary reviews for services requiring prior authorization; maintains accurate claims records; collaborates with clinical and administrative teams; processes authorization review requests timely; and upholds all applicable regulatory, contractual, and compliance requirements including HIPAA.
Candidates should have an Associate's degree or equivalent experience (Bachelor's preferred), active certification in Medical Coding or equivalent, and 5+ years professional healthcare, managed care, or insurance experience. Proficiency in English and strong customer service and problem-solving skills are required.
VitalCore offers a robust benefits package including medical, dental, vision, paid holidays, short/long-term disability, life insurance, HSA, 401K with matching, PTO, employee assistance programs, and more.
VitalCore Health Strategies is an equal opportunity employer committed to an inclusive workplace where all employees can contribute and are valued for their skills and perspectives.
- Associate's degree or equivalent experience; Bachelor's degree preferred
- Active certification in Medical Coding or equivalent experience
- 5+ years professional experience in healthcare, managed care, or insurance preferred
- Education, training, or experience in medical coding, billing, or insurance coordination
- Proficiency in English reading, writing, speaking, and comprehension
- Ability to work collaboratively in a team environment
- Sound judgment and independent decision-making
- Professional and tactful interaction with staff, family members, visitors, government agencies, and the public
- Leadership and supervisory skills
- Commitment to maintaining a safe and professional work environment
- Proficiency with Microsoft Office, including Excel
- Knowledge of CPT and ICD coding, reimbursement policies, and utilization management guidelines
- Adherence to HIPAA and confidentiality requirements
- Paid holidays (New Year's Day, MLK Jr. Day, Memorial Day, Juneteenth, Independence Day, Labor Day, Veteran's Day, Thanksgiving, Christmas)
- Medical, dental, vision insurance
- Health Savings Account
- Dependent Care Flexible Spending Account
- Life insurance
- Short-term and long-term disability
- Identity theft protection
- Pet insurance
- Employee assistance program and discount center
- 401K with plan matching
- Paid time off
Location
Massachusetts, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$65,000 - $75,000
Remote work allowed
No
Posted
1 week ago