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Claims Specialist


The Claims Specialist adjudicates claims for all product lines of VNSNY CHOICE. Performs root cause analysis for all provider projects to identify areas for provider education and/or system (re)configuration. Initiates and follows through with resolution of all pended claims, (re)pricing, return/refund checks and the development of provider and facility compensation grids. Provides feedback or suggestions to enhance current processes and/or systems.

  • Reviews, investigates and adjudicates claims for medical and non-medical services that involve the application of contractual provisions in accordance with provider contracts and authorizations

  • Processes claim adjustments resulting from external providers, vendors and internal inquiries in a timely manner

  • Investigates suspense conditions to determine if system or procedural changes would enhance claim workflow

  • Communicates and follows up with a variety of internal and external sources including but not limited to providers, members, attorneys, regulatory agencies and other carriers on any claim related matters

  • Analyzes patient and medical information to identify COB, Worker's Compensation, No-Fault and Subrogation conditions

  • Assigns appropriate ICD10-CD, HCPCS and CPT4 codes as well as other codes necessary to process claims based on claim information submitted

  • Validates DRG grouping and (re)pricing outcomes presented by the claims processing vendor

  • Attends meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines

  • Assists with provider compensation configuration by creating and testing compensation grids used for reimbursement and claims processing

  • Ensures that refund checks are logged and processed enabling expedited credit of monies returned

  • Analyzes check return/refunds volumes and trends to determine root causes. Proposes workflow changes to correct and enhance claim processes to prevent returned checks/refunds

  • Generates routine daily, monthly and quarterly reports used for managing process timeframes and vendor productivity,ensuring compliance with all regulatory requirements and contractual vendor SLAs

  • Participates in special projects and performs other duties, as assigned


Education: Associate’s degree or the equivalent combination of education and experience required.

Experience: Minimum of two years claims processing experience required, preferably working in a TPA, HMO or managed care environment. Knowledge of Medicare claims processing rules and coding experience with DRG, ICD10 and CPT4 is required. Hospital Claims experience required. Proficient PC skills, including Microsoft Windows required. Knowledge of HIPAA guidelines required. Excellent communication and analytical skills also required.

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The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.