Claims Specialist

Job Description:

Who We Are:

Nonstop Administration and Insurance Services, Inc. is a fast-growing health insurance organization with a firm belief that everyone should have access to high-quality, affordable healthcare. We offer an employer-sponsored group health insurance solution called Nonstop Wellness to achieve this goal.

What Nonstop Is Looking For:

Nonstop Health is seeking a detail-oriented and motivated Claims Specialist to join our growing team. In this role, you will be responsible for reviewing and processing medical expense reimbursement claims submitted by Nonstop Health members.

The ideal candidate brings strong critical thinking, attention to detail, and problem-solving skills. You’ll be expected to evaluate claim documentation accurately, apply eligibility rules consistently, and make timely benefit determinations. This role involves managing a high-volume, active caseload and collaborating closely with both members and internal teams to ensure accurate, compliant, and customer-friendly claims processing.

Primary Responsibilities

• Review and verify accuracy of MERP reimbursement claims and supporting documentation (e.g., EOBs, provider bills, receipts)
• Ensure claims meet plan eligibility and MERP-specific policy guidelines, including IRS-qualified expense criteria
• Make benefit determinations by applying plan rules, allowable expense definitions, and medical necessity standards
• Manage and maintain a caseload of 60+ client files, tracking each claim’s status and required follow-up
• Accurately enter and process claim data into the MERP claims management and payment systems
• Identify incomplete or non-allowable claims and request additional documentation as needed
• When necessary, communicate clearly and compassionately with members and providers regarding claim status, documentation requirements, and denials
• Coordinate closely with internal departments (e.g., Member Services, Development, Appeals etc.) to resolve issues and expedite claims
• Adjudicate claims in a timely and compliant manner, issuing approvals, denials, or payment adjustments as appropriate
• Initiate and monitor claim payment processes, ensuring timely check generation and mail distribution
• Maintain meticulous claim records for audit readiness and compliance with HIPAA and internal data privacy standards
• Support and uphold Nonstop’s commitment to quality member experience and efficient claims resolution