Health Plans Claims Processor

Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes - making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra Health is looking for a Claims Resolution Representative to join our growing team.

Job Summary: The Claims Resolution Representative plays a vital role in ensuring accuracy and adherence to the applicable state’s Department of Health 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.

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 (paper or electronic) and process them according to Wyoming Department of Health policies and procedures.

Possess an unwavering commitment to customer service and operational excellence.

Perform manual pricing and audit checks to ensure compliance with Wyoming policies and rules.

Review and process suspended claims and submitted documentation.

Provide sufficient detail to explain claims denial reasons.

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.

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.

Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

High School Diploma or GED

Be available to work from 8:00 AM to 5:00 PM Mountain Time on all state business days, Monday through Friday (excluding state holidays)

Strong computer skills, including proficiency in Microsoft Word and Excel, with the ability to navigate multiple claims and eligibility systems simultaneously

Outstanding customer service skills with the ability to interact professionally, tactfully, and empathetically while maintaining appropriate boundaries

Knowledgeable in claims review and analysis

Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

For non‑clinical roles, or when not required by the contract specifically, the Company acknowledges that practical, hands‑on experience can provide skills and competencies equivalent to formal education. As such, in cases where a Bachelor’s degree may be required, the Company will accept a minimum of six (6) years of directly relevant professional experience in lieu of a degree. In instances where the candidate has an Associate’s degree, the Company will accept a minimum of three (3) years of directly relevant professional experience in lieu of the Bachelor’s degree.

EEO AA M/F/Vet/Disability. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

USD $18.62 - USD $21.00 per hour.

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