Claims Resolution Specialist I

JOB SUMMARY: This position is responsible for contacting healthcare providers to discuss negotiations for a specific dollar range of eligible claims/bills prior to payment, in order to achieve maximum discounts and savings on behalf of payor/client.

JOB ROLES AND RESPONSIBILITIES:

1. Manage a high volume of healthcare claims thoroughly to maximize savings opportunities on each claim within the established department production standards and individual goals by contacting provider on all assigned claims and presenting a proposal while maintaining high quality standards.

• Perform provider research to provide support for desired savings

• Address counter-offers received and present proposal for resolution while adhering to client guidelines and policy and procedures

• Seek opportunities to achieve savings with previously challenging/unsuccessful providers

• Seek opportunities to establish ongoing global or concurrent agreements for future claims

• Update provider data base for reference and claims processing on subsequent claims

1. Initiate provider telephone calls as often required with respect to proposals, overcome objections and apply effective telephone negotiation skills to reach successful resolution on negotiated claims.

• Up to 40% of time will be on phone with providers

• Provider education to providers online provider portal services available for proposal review and approval

1. Meet and maintain established departmental performance metrics
2. Handle post claim closure service inquires, including payment status and defending original negotiation terms.
3. May require ACD phone responsibilities and tracking outcomes.
4. Collaborate, coordinate, and communicate across disciplines and departments.
5. Ensure compliance with HIPAA protocol.
6. Demonstrate Company's Core Competencies and values held within.
7. Please note due to the exposure of PHI sensitive data - this role is considered to be a High Risk Role.
8. The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.

JOB SCOPE:

The Individual adheres to company policies and customer specific procedures to meet control standards. The Individual relies on established instructions and procedures, applies basic skills and may develop advanced skills using tools and equipment appropriate for the position. Duties and tasks are standardized and generally contain written instructions, allowing an individual to resolve routine questions and problems, and referring more complex issues to a higher level. Work is subject to defined work output standards and production which involves high volume claims resolution. Work involves direct contact with internal and external customers.

JOB REQUIREMENTS (Education, Experience, and Training):

1. Minimum high school diploma or GED
2. Minimum 6 months experience in the health care industry (provider billing, medical coding, provider collections, insurance or managed care); 1 year preferred
3. Knowledge of applicable laws and statutes (state, local or federal) for positions focusing on Workers' Compensation or automobile medical ("auto") bills a plus
4. Knowledge of general office operations and/or experience with standard medical insurance claim forms
5. Good Communication (verbal, written and listening) teamwork, negotiation and organizational skills
6. Ability to process verbal and written instructions
7. Display professionalism by having a positive demeanor, proper telephone etiquette and use of proper language and tone in a business professional environment.
8. Ability to:

• Commit to providing a level of customer service within established standards

• Provide attention to detail to ensure accuracy including mathematical calculations

• Identify issues and determine appropriate course of action for resolution

• Organize workload to meet deadlines and participate in department/team meetings

• Adjust/alter workflow to meet deadlines in a fast-paced environment

• Work independently and handle confidential information

1. Ability to use software and hardware related to job responsibilities, including MS Word and MS Excel spreadsheets and database software
2. Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone

COMPENSATION

The position pays $20.23 per hour. Specific offers take into account a candidate's education, experience and skills, as well as the candidate's work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity.

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