Claims Representative

Job Title: Claims Resolution Representative

Location: Remote

Position Type: Contract position

Responsibilities:

Job Summary:

The Claims Resolution Representative plays a vital role in ensuring accuracy and adherence to the applicable guidelines. This position serves as a crucial liaison between members, providers, agencies, and the internal claims department, demonstrating leadership, collaborative skills, and commitment to achieving results.

*This position is remote within the United States, but applicants can expect to work Eastern Time regular business hours with some flexibility.

Responsibilities:

• Independently resolve suspended claims using the resolution screens in accordance with operational procedures and process recoupments.
• Determine when to use a "Forcible" disposition to override the edit and process the claim based on operational claims adjudication procedure.
• Review and analyze claims and follow up on the status of claims and reimbursement.
• Interpret and apply policy and reimbursement rules to support provider inquiries.
• Ensure accuracy and consistency in claims processing.
• Research and review submitted claims (electronic) and process them according to policies and procedures.
• Possess an unwavering commitment to customer service and operational excellence.
• Perform manual pricing and audit checks to ensure compliance with policies and rules.
• Review and process suspended claims and submitted documentation.
• Provide sufficient detail to explain claims denial reasons.
• Implement workflow processes and capabilities for work queues with the ability to route workstreams.
• Approve or deny requests for transportation authorization from providers, verify member transportation claims, and process approved claims.
• Perform manual reviews on claims, documents, and attachments.
• Release individual claims for providers on review.
• Independently resubmit claims with applicable corrections.
• Independently address discrepancies in charges, payments, adjustments, and demographic information.
• Facilitate manual entry of claims into the system.
• Review paper claims and attachments, scanning them using scanning equipment to attach the documents to corresponding transaction control numbers.
• Other duties as assigned.
• Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Required Qualifications:

• High School Diploma or GED
• 1+ years of experience conducting research to resolve issues within the healthcare field

Preferred Qualifications:

• Ability to maneuver through various computer claims and eligibility platforms simultaneously
• Outstanding customer satisfaction skills
• Must be firm but professional when interacting with contacts while performing tasks
• Friendly personality, tact, patience, empathy, and a helpful yet professional attitude are essential
• Strong computer skills, including proficiency in MS Word and Excel
• Excellent oral and written communication skills
• Excellent organization and time management skills, with the ability to establish priorities effectively
• Ability to read, write, and follow directions
• Self-directed and capable of working without direct supervision
• Ability to collaborate effectively with others
• Create and maintain a positive atmosphere, demonstrating leadership qualities
• Knowledgeable in claims review and analysis