Claims Resolution Specialist

Job Purpose This role makes sure agents complete their department work on time and with accuracy. It also collects, organizes, and analyzes data so payer trends and claim adjudication outcomes are easier to predict. Pay range $23 – $28 hourly Employment Full-Time Location In-Office (Costa Mesa, CA) Department Negotiations Job Purpose This role makes sure agents complete their department work on time and with accuracy. It also collects, organizes, and analyzes data so payer trends and claim adjudication outcomes are easier to predict. Duties & responsibilities 01If needed, maximize productivity while performing timely claim follow-up, and contact negotiators each day to confirm they received a response or to clarify a counterargument. 02Own follow-up, research, and coordination for proposed negotiations and claim denials across the portal, scanned documents, faxes, and email, and keep those records easy to find. 03Document and update payment information in CollaborateMD, and organize the work schedule around Jira due dates. 04Use CMD, the Anthem Claims Routing tool, Kipu, the Reimbursement Tool, and Availity to compare past payment rates for similar members or facilities. 05Handle high-level escalations for BPO agents, and send complex claims and challenges to department leadership as they come in. 06Watch net gain, net loss, and the KPIs for assigned work, and use those results to set priorities and spot improvements. 07Support BPO agents on daily negotiations and on weekly and monthly TPP submissions, and audit claim work for accuracy, completeness, compliance, and training gaps. 08Track BPO KPIs and report underperformance to department leadership so they can build an action plan. 09Participate in the department's L10 meetings, identify and bring issues, and develop and execute quarterly rocks to drive alignment and improvements toward Cipher VTO. 10Perform other related duties as assigned. #J-18808-Ljbffr Cipher Billing