Summary
 

Researches and resolves escalated, complex, and high profile claims issues. Serves as POC (point of contact) with various professional and facility/hospital providers in the research and resolution of all claims issues. May assist with escalated issues to include, but not limited to provider enrollment, medical review, appeals and/or finance. Completes research efficiently and accurately to ensure the departmental goals are achieved.

Description
 

• Researches and resolves high profile claims issues. Ensures claims processing errors are corrected according to the appropriate provider reimbursement contract. May also research and resolve high profile issues including, but not limited to provider enrollment, medical review, appeals and/or finance, which may be received via written or telephone correspondence.
• Serves as Point of Contact for various providers (professional and facility) to resolve all claims payment errors. Conducts weekly conference calls with assigned providers to ensure open communication pertaining to all current issues.
• Communicates/educates providers on proper coding of claims, claims filing, pricing concerns, contract questions, benefit/system updates, etc.
• Determines if claims payment errors are the result of system issues. Troubleshoots, and/or coordinates the resolution/correction of the system processing error.
• Verifies disbursement requests to ensure the request is valid and appropriately documented. Research rejected, transition, and paid status claims for validity and escalate as appropriate. Uses the various systems of the department/company to complete research.
• Monitors inventory reports to ensure claims are resolved accordingly. Provides documentation as requested for audit purposes. May provide written or telephone correspondence to resolve claims issues.
• Required Education: High School Diploma or equivalent
• Required Work Experience:
• 5 years of combined claims and provider service experience in a healthcare environment.
• 3 years of experience with claims systems (may be concurrent).
• Required Skills and Abilities:
• Comprehensive knowledge of claims payment policies and refund policies.
• Working knowledge of related claims software systems.
• Knowledge of medical terminology and coding as appropriate.
• Strong analytical skills and the ability to retrieve and research automated reports. Strong time management skills and adaptable to change.
• Strong communication (verbal and written) communication skills.
• Required Software and Tools:
• Standard office equipment.
• Preferred Education:
• Bachelor's degree-in Business, Computer Science, Healthcare Administration, or a related field.
• Preferred Skills and Abilities:
• Ability to run reports using pre-set data retrieval applications, such as DB2 and EZTRIEVE Plus, to obtain information for research and analysis.
• Work Environment:
• Typical office environment.

 

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