Claim Dispute & Strategy Analyst

POSITION SUMMARY :

The Claim Dispute & Strategy Analyst is responsible for researching state and payor protocols and analyzing eligible claims that receive under payment or non-payment.  This position oversees the billing vendor and process of dispute resolution, claim submission and payment requests with payors and third-party dispute resolution entities. Translate data into meaningful information and knowledge that supports decision-making or determining action that drives performance improvement and quality. Influence designated payor policy changes to impact product coverage.

PRIMARY RESPONSIBILITIES:

• Serves as a source of knowledge for the designated payor operations and performance.
• Complete position responsibilities within the appropriate time frame while adhering to quality standards.
• Translate data into meaningful information and knowledge that supports decision-making or determining action that drives performance improvement and quality.
• Influence contract negotiations with designated out-of-network payors.
• Track outcomes of payment resolutions, appeals, and negotiated claims to ensure goals are met.
• Performs analysis, identifies trends, and presents opportunities for designated payors to increase ASP and revenue.
• Participates in weekly meetings to review key metrics, workflows, trends, payor performance improvement opportunities, and strategies.
• Continuously seeks new and creative technologies that help identify and guide improvement opportunities that align with overall company success.
• Provides recommendations by performing analysis of operational, production, and other data of designated payor.
• Analyzes payor behaviors, systems, and processes to determine pathways available for advanced filings.
• Analyzes reimbursement from all sources, including carrier reimbursement and follow-up on pending claims and denial management.
• Researches complex benefits and insurance verification using various systems and portals internal and external.
• Investigate designated payors' literature and agencies, and stay current on new indicators, such as state statutes and laws, and other requirements.
• Identify and escalate missing information across departments to manage the accuracy of patient records.
• Responsible for verifying patient insurance coverage, to ensure necessary procedures are covered by an individual’s provider.
• Auditing data for accuracy of patient benefit information in multiple systems and verifying existing information.
• Monitors and validates adherence to Policies and Procedures, auditing as necessary.
• Coordinates with Management to ensure a thorough understanding of trends/issues affecting payor trends.
• Develops, manages, and monitors successful completion of implementation of projects with vendors.
• Manages all aspects of the denial management for designated payors including timely and accurate advanced filing submissions and outreach for all patient authorizations, as assigned.
• Handles escalations requiring specialized and advanced reviews including state and federal arbitration entities, CMS, and the Department of Insurance.
• Partner with multiple internal cross-functional teams and successfully manage multiple product projects simultaneously.
• Establishes an ongoing working relationship with other departments impacting designated payors' performance.
• Works closely with vendor operations to oversee activity that directly impacts designated payors to accurately process actions on time.
• Communicates designated payor performance in operations and methodologies to related teams and departments.
• Presents information, analysis, and updates to various levels and types of audiences.
• Communicates and cooperates with state and federal agencies to enforce statutes and laws.
• This role works with PHI on a regular basis both in paper and electronic form and utilizes various technologies to access PHI (paper and electronic) in order to perform the job.

The pay range is listed and actual compensation packages are based on a wide array of factors unique to each candidate, including but not limited to skill set, years & depth of experience, certifications and specific office location. This may differ in other locations due to cost of labor considerations.Remote USA$77,000—$96,300 USD

OUR OPPORTUNITY

Natera™ is a global leader in cell-free DNA (cfDNA) testing, dedicated to oncology, women’s health, and organ health. Our aim is to make personalized genetic testing and diagnostics part of the standard of care to protect health and enable earlier and more targeted interventions that lead to longer, healthier l