Claims Research Specialist

Martin's Point Health Care | Portland, ME

Posted Date 9/15/2020

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary: Under general supervision, the Claims Research Specialist will process the complex claim types following department policies and procedures. In addition, the Claims Research Specialist will review all claim disputes received by the claims department. This position will also work closely with the Claims Documentation Specialist in the claim processes, and monitoring of benefits changes that will affect claims processing. Ad hoc duties will include representing department interests on committees and special projects.

Key Outcomes:

  • Reviews Provider disputes concerning Claims Editing System (CES) and coding denials.
    • Upholds denials based on CMS/TRICARE regulations, Coding guidelines, and Martin’s Point policies.
    • Overturns denials if found system is not applying CMS/TRICARE regulations, Coding guidelines, and Martin’s Point policies correctly. The discrepancy will be documented by the Benefit Administration Department and reviewed for system updates.
    • Reports to the Claims Manager and the Benefit Administration Manager quarterly the financial outcome of Upheld and Overturn denials based on CMS/TRICARE regulations, Coding guidelines, and Martin’s Point policies.
  • Reviews all documentation updates to verify accuracy of the determinations made by the Benefit Administration Department regarding benefit and process changes.
  • Review, research and resolve the most complex claims related issues.
  • Researches regulatory authority to identify incorrect processing of claims resulting in claims incorrectly being approved or denied. Proactively review new regulatory advisories for their impact to the Claims Department.
  • Serves as interdepartmental liaison for various departments responsible for verifying changes made are within claims capability to perform. The Claims Research Specialist will also provide support regarding claims administration, procedural coding and billing.
  • Assists in the audit, coaching and feedback process as needed.
  • Provides support regarding claims administration, procedural coding and billing. Actively works within the Claims Department to be a resource for complex claim types, Claims Editing System processing, and Medical Coding questions.
  • Supports the Appeals Department with verification of claims processes and documentation of the disposition of a claim in question.
  • Represents the Claims Department on interdepartmental committees and work-groups.
  • Processes of claims that are submitted with unlisted procedure CPT codes. Verifies that procedure code has been authorized, and is allowed for payment per Current Procedural Terminology (CPT) coding guidelines, CMS and TRICARE regulations, and researching to find a comparable CPT code for pricing purposes.
  • Assists in training needs of the Claims Department.
  • Provides documentation for provider and member escalated calls as well as the monthly Provider meetings as to the validity of claims that are in dispute.
  • Coordinates with the Documentation Specialist to aid in the implementation of any process changes.
  • Performs all other duties as assigned.


  • Certification as a Professional Coder (CPC) preferred but not required.
  • Associate Degree or combination of relevant education and experience.
  • 3+ year(s) experience in a health care/managed care organization.
  • Medical claims processing experience
  • Proven organizational, communication and informal leadership skills.

Skills/Knowledge/Competencies (Behaviors):

  • Demonstrates an understanding of and alignment with Martin’s Point Values.
  • Strong interpersonal and communication skills are essential. Presentation skills are a plus.
  • Reasonable schedule flexibility is needed in order to attend interdepartmental meetings.
  • Proven capacity to give and receive feedback in a constructive manner.
  • Knowledge of all phases of claims adjudication process.
  • Maintains an active role in professional development and continuing education.
  • Maintains knowledge of correct coding guidelines, LCD and NCD guidelines.
  • Knowledge of Health Care industry standards.
  • Third party insurer claims/billing knowledge helpful.
  • Must be proficient in use of terminal/PC keyboard, prior experience with computers and work processing preferred.
  • Capable of determining when issues need escalation of prioritization and have reliable follow through.
  • Ability to maintain confidentiality of claim/healthcare data.
  • Ability to work independently and as a team member with minimal direct supervision and effectively implement oral and written instructions.
  • Must exhibit all MPHC core competencies as indicated below:

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at:

Geographic Region
Greater Portland/Casco Bay
Healthcare | Science - Research

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