Regional Claims Resolution Coordinator

Medical Claims Resolution Coordinator

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 14 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

The Medical Claims Resolution Coordinator provides research and resolution to provider disputes, escalated claims inquiries, and claims projects to government and Health Plan regulations. This position is responsible for root cause analysis and implements resolution for all provider issues regarding claims adjudication.

Position Duties & Responsibilities

• Review and acknowledges disputes within AZPC, DOHC & Medicare policy guidelines.
• Requests additional information within a timely manner.
• Assures payment or denial within the deadline set forth in the AZPC & DOHC policy.
• Assures payment is made within a required number of days from the determination or approval.
• Maintains PDR Log.
• Retains PDRs onsite for the required time.
• Keeps up with revisions to the PDR process and updates language on acknowledgement letters.
• Corresponds with providers to educate proper submission of appeals.
• Examines, enters and adjudicates medical claims for accuracy, completeness, authorization, referrals, eligibility and benefits.
• Is knowledgeable of HMO and provider contracts, Managed Care Operations, benefits and payment responsibility for accurate decision making.
• Reviews and adjusts resubmitted/corrected claims.
• Point of contact for Claims department requests for adjustments.
• Identifies trends and automation opportunities and shares recommendations for staff training.
• Coordinates requests for contract updates and system configuration.
• Collaborates with various departments to ensure system, documentation, and processes are up to date for appropriate claims adjudication.
• Assists with other projects as assigned

Education, Training and Experience

• High school diploma or equivalent (GED).
• Minimum two years claims processing experience.
• Knowledge of Medicare rules, medical terminology, and managed care health plan rules and regulations, CPT, HCPCS, ICD-10 and RSV codes.
• Experience with both professional and facility claims.
• Strong knowledge of Medicare Billing & Payment Guidelines as well as CMS CCI Edits.
• Familiar with all regulatory requirements including CMS and DHS.
• Strong attention to detail.
• EZ-Cap experience is a plus.
• Must be able to work independently, exercise judgment and communicate effectively.

Must be able to work on computer systems, accessing multiple files and programs.

This role requires FT in-office presence for the first 60 days of employment. Hybrid schedule available after initial training period.

Compensation range: The hourly range for this position is: $23-$26