Reconciliation Representative (Onsite - San Diego, CA)

American Specialty Health Incorporated (ASH) is seeking a Reconciliation Representative to join our Claims department.

The primary function of this position is to reconcile claims, including complex claims, for payment as per Explanation of Benefits from Health Plan Payors for 2-step accounts.

Responsibilities

• Reconciles, resolves, and researches 2-step claims and payments to ASH.
  • Receives and sorts incoming mail including paper EOBs, faxes, Interoffice Mail, and Health Plan letters.
  • Downloads electronic EOBs from Health Plan Portals.
  • Count and scan EOBs and Health plan letters for distribution and track counts into daily inventory.
  • Manually reconciles claims for payment from Health Plan Payors received by paper EOBs or spreadsheets.
  • Makes calls to Health Plans to check status of claims which may include payment or underpayment. In addition will request claims to be reprocessed if denied in error.
  • Uses Health Plan and TPA websites to check on claim status or reconcile claims.
  • Reconciles claims from various reports including but not limited to 14-day reports, MO copay, fee schedule reports, unreconciled reports and rejected reports.
  • Notifies supervisors of trends related to invalid denials by TPAs or Health Plans.
  • Documents comments in internal notes fields in IHIS in addition to spreadsheets being worked.
  • Meets department production and quality requirements.
  • Maintains confidentiality of all claims documents, records, and claims related issues.
  • Promotes a spirit of cooperation and understanding among all personnel.
  • Attends organizational meetings and trainings as required.
  • Attends department meetings.
  • Adheres to organizational policies and procedures.
  • Recognizes unique and/or problem situations within area of assigned responsibility. Researches and makes recommendations to Supervisor.
• Provides assistance and teamwork to Claims Department staff in accomplishment of routine duties and special projects.
• Performs other duties and responsibilities as assigned.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• High School Diploma or GED certificate required.
• 2 years with claims processing, computer, typing, 10-key, and telephone skills required.
• Knowledge of Microsoft Word and Excel helpful.
• Familiarity with Managed Care, HMO, PPO health plan provisions.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
• Ability to effectively organize, prioritize, multi-task and manage time.
• Demonstrated accuracy and productivity in a changing environment with constant interruptions.
• Demonstrated ability to analyze information, problems, issues, situations, and procedures to develop effective solutions.
• Ability to exercise strict confidentiality in all matters.

Mobility

• Primarily sedentary, able to sit for long periods of time.

Physical Requirements

• Ability to see, speak, and hear other personnel and/or objects. Ability to communic