Claims Adjustments Examiner (Remote) - (Must Reside near Cheyenne, Wyoming)

 Following a 2022 merger of CNSI and Kepro, Acentra Health combines clinical services, technology solutions, and data analytics to accelerate better health outcomes. This is a great time to join our team of passionate individuals working together to pursue the most effective solutions to today’s complex healthcare challenges. Our culture is fueled by passion and driven by purpose.

Position Overview

Acentra Health Claims Adjustment Examiner will play a crucial role in the resolution of billing and claim discrepancies, performing detailed bill-specific research and executing adjustments as mandated by the Wyoming Department of Health. These professionals are pivotal in ensuring the accurate and prompt investigation of all types of claim disputes and the efficient processing of adjustments. They serve as essential intermediaries between healthcare providers, the agency, and the internal claims department, facilitating clear and constructive communication across all parties.

Key responsibilities include evaluating claims to determine the necessity for recalculations and adjustments to payment amounts, ensuring all actions are carried out with precision and in a timely manner. This role demands a high level of leadership, collaborative spirit, and a track record of achieving significant results. The ideal candidate will be adept at developing and mentoring team members, demonstrating exemplary attendance, and fostering a positive team environment. A strong commitment to upholding policies and enhancing team morale is essential.

Located in Cheyenne, Wyoming, this position offers the opportunity to make a significant impact within the healthcare sector by ensuring the fairness and accuracy of claims processing. The successful candidate will embody teamwork and support leadership initiatives, contributing to the overall effectiveness and positive culture of the team.

Job Responsibilities

• Efficiently review, scan, and attach paper adjustments and related documents to their corresponding transaction control numbers using state-of-the-art scanning equipment.
• Conduct thorough research and review of both paper and electronic claims requesting adjustments. Process these adjustments meticulously in alignment with the Wyoming Department of Health's policies and procedures.
• Commit to full-time availability from 8:00 AM to 5:00 PM Mountain Time, Monday through Friday, excluding Wyoming State holidays, to ensure consistent operations.
• Examine documentation accompanying checks to determine the correct application of payments to claims as specified by healthcare providers.
• Independently resubmit claims with appropriate corrections, addressing any discrepancies in charges, payments, adjustments, and demographic information autonomously.
• Identify any additional information required to finalize adjustments, voids, or the processing of submitted checks, and proactively communicate with providers to gather any necessary details.
• Accurately input the necessary adjustments into the claims system, adhering strictly to contractual obligations and specified timelines.
• Processing of claims and adjustments, embodying a relentless dedication to customer service and operational excellence.
• Oversee and streamline the review and processing of suspended claims and accompanying documentation, including manual claims entry into the system
• Independently manage and resolve suspended claims utilizing resolution screens, in accordance with established operational guidelines, and process recoupments as needed.
• Execute manual pricing and audit checks diligently to ensure strict compliance with Wyoming's policies and rules.
• Interpret and enforce policy and reimbursement rules accurately to address and support provider inquiries effectively.
• Implement efficient workflow processes and capabilities for managing work queues, facilitating seamless workstream.
• Perform detailed manual evaluations of claims, documents, and attachments, releasing claims for provider review as required.

Required Qualifications, Skills, Knolwedge and Experience

• Possession of a High School Diploma or a General Education Development (GED) certificate.
• Proven experience in conducting detailed research to address and resolve issues within the healthcare sector.
• Demonstrated ability to efficiently navigate and manage multiple computerized claims processing and eligibility verification platforms.
• Exceptional skills in delivering outstanding customer service, characterized by a commitment to resolving customer concerns with a blend of professionalism and personal touch.
• Must possess a friendly demeanor, coupled with tact, patience, empathy, and the ability to maintain a constructive and profess