Senior Medical Claims Resolution Specialist

At Claritev, we pride ourselves on being a dynamic team of innovative professionals. Our purpose is simple - we strive to bend the cost curve in healthcare for all. Our dedication to service excellence extends to all our stakeholders – internal and external - driving us to consistently exceed expectations. We are intentionally bold, we foster innovation, we nurture accountability, we champion diversity, and empower each other to illuminate our collective potential.

 

Be part of our amazing transformational journey as we optimize the opportunity towards becoming a leading technology, data, and innovation voice in healthcare. Onward and Upward!!!

    JOB SUMMARY:
This position is responsible for negotiating certain type and dollar size of assigned claims/bills that are more complex on behalf of the payor to achieve maximum discount and savings. In addition, this job may also be responsible for coaching and mentoring.   JOB ROLE AND RESPONSIBILITIES:   1. Foster and maintain provider relationship to facilitate current and future negotiations by
* Performing claim research and analysis to provide support for desired savings.
* Generating agreement by communicating with provider by written and verbal communication throughout the negotiation process; and
* Partnering with internal and external clients, including Account Managers, Customer Relations, Provider Services, and direct client contacts as applicable.
2. Meet and maintain established departmental performance metrics. Manage high volume of claims in a queue; keep current with all claim actions and meet client deadlines for working and closing claims.
3. Initiate provider telephone calls with respect to proposals, overcome objections and apply effective telephone negotiation skills to reach successful resolution on negotiated claims.
4. Address counteroffers received and present proposal for resolution while adhering to client guidelines and department goals.
5. Identify and seek opportunities to achieve savings with previously challenging/unsuccessful providers.
6. Participate in projects and initiatives, as necessary.
7. Collaborate, coordinate, and communicate across disciplines and departments.
8. Ensure compliance with HIPAA protocol.
9. Demonstrate Company Core Competencies and values held within.
10. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
11. 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 incumbent works under limited supervision to complete job responsibilities in applying a fundamental knowledge of principles, practices and procedures related to the negotiation of provider agreements. Work is more complex and requires independent judgment within established guidelines. This job has regular contact with internal and external customers, as well as medical review staff. While this is not a supervisory position, an incumbent acts as a resource to other team members and management. Qualifications JOB REQUIREMENTS: (Education, Experience, and Training)   * Minimum high school diploma or GED
* Minimum Bachelor's degree (B.A.) in related field preferred
* Minimum 3 years of experience in the health care or medical insurance industry (clinical, provider billing, provider collections, insurance, or managed care), or 1 year experience as a Claims Resolution Specialist
* State licensure certification, including NY Health and/or P&C State Adjustor license, may be required. If hired without certification, certification must be obtained, and maintained thereafter, within six months of notification. If the required state licensure certification(s) are not obtained or renewed within six months of notification, an employee may be moved to a position within a relevant job family that does not require certification/licensure, if and when such position is available. When an alternate position is unavailable, other employment actions may be implemented consistent with MultiPlan practice and policy.
* Knowledge of medical coding systems (i.e., CPT, ICD-9/10, revenue codes) desired
* Knowledge of commonly used medical data resources.
* Knowledge of general office operations and/or experience with standard medical insurance claim forms
* Knowledge of applicable laws and statutes (state, local or federal) for positions focusing on Workers' Compensation or automobile medical ("auto") bills
* Communication (verbal, written and listening), teamwork, negotiation, and organizational skills.
* Ability to use clinical and coding based knowledge to negotiate applicable claims.
* Ability to provide attention to detail to ensure accuracy including mathematical calculations.
* Ability to commit to pr