Claims Specialist

2 days ago

Vaughan, Ontario, Canada Nonstop Administration & Insurance Services Full time

Description
Who We Are:
Nonstop Administration and Insurance Services, Inc. is a fast-growing health insurance company committed to making high-quality, affordable healthcare accessible to everyone through our employer-sponsored solution, Nonstop Health. Here, you're joining more than a job—you're part of a mission to transform how brokers, clients, and members experience healthcare. You'll help build strong partnerships, grow our client base, and deliver exceptional service that truly makes a difference. We move fast, work efficiently, and innovate constantly—from automation to new products—so you can make an impact and help shape the future of healthcare.

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

Requirements
Qualifications:

  • Understanding of IRS guidelines for qualified medical expenses and MERP plan structures
  • Familiarity with EOBs, provider statements, and healthcare billing practices
  • Proficiency in claims and payment systems, as well as Microsoft Office tools
  • Strong attention to detail, problem-solving skills, and ability to manage high-volume workloads
  • Excellent verbal and written communication skills
  • Commitment to confidentiality, accuracy, and member-centered service

Preferred Skills, Experience And Education

  • High school diploma or equivalent required; associate's or bachelor's degree preferred
  • 1–3 years of experience in claims processing, healthcare administration, or reimbursement plan operations (MERP experience preferred)
  • Applies critical thinking and balanced judgment to solve problems and drive confident decisions
  • Experience working with Salesforce and Atlassian systems preferred
  • Must demonstrate proficiency in AI-driven tools and solutions to improve processes, optimize performance, and support continuous innovation

Work Environment And Essential Functions Of The Job

  • Remote role with regular collaboration via video, phone, email, and messaging platforms
  • Ability to travel for team meetings, trainings, or company events
  • Access to a quiet, distraction-free workspace suitable for confidential work
  • Reliable high-speed internet connection
  • Collaborates efficiently and communicates clearly in fast-paced, cross-functional environments
  • Ability to use a computer and productivity software for extended periods
  • Ability to communicate clearly in both verbal and written formats
  • Reasonable accommodations will be provided as needed

Why You'll Love Working Here

  • Health, fully covered: 100% of medical, dental, and vision premiums for you and your dependents
  • Fully remote position
  • Technology allowance
  • Flexible PTO and holidays
  • Financial wellness: 401(k) match
  • Make an impact: Your work truly matters every day
  • Pay Rate - $28.85

Employment Eligibility
Applicants must be legally authorized to work in the United States without current or future sponsorship. Nonstop is unable to sponsor or assume sponsorship of employment visas at this time.

Nonstop provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

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