Claims Resolution Specialist

Duties

• Manage a high volume of healthcare claims thoroughly to maximize savings opportunities on each claim within the established department production standards and individual goals by contacting provider on all assigned claims and presenting a proposal while maintaining high quality standards.
• Perform provider research to provide support for desired savings.
• Address counteroffers received and present proposal for resolution while adhering to client guidelines and policy and procedures.
• Seek opportunities to achieve savings with previously challenging/unsuccessful providers.
• Seek opportunities to establish ongoing global or concurrent agreements for future claims.
• Update provider data base for reference and claims processing on subsequent claims.
• Initiate provider telephone calls as often required with respect to proposals, overcome objections and apply effective telephone negotiation skills to reach successful resolution on negotiated claims.
• Up to 40% of time will be on phone with providers.
• Provider education to providers online provider portal services available for proposal review and approval
• Meet and maintain established departmental performance metrics.
• Handle post claim closure service inquires, including payment status and defending original negotiation terms.
• May require ACD phone responsibilities and tracking outcomes.
• Collaborate, coordinate, and communicate across disciplines and departments.
• Ensure compliance with HIPAA protocol.

Qualifications

• Minimum high school diploma or GED
• Minimum 6 months experience in the health care industry (provider billing, medical coding, provider collections, insurance, or managed care); 1 year preferred.
• State licensure certification, including NY Health and/or P&C State Adjustor license, may be required. If hired without certification, certification must be obtained, and maintained thereafter, within six months of notification.
• If the required state licensure certification(s) are not obtained or renewed within six months of notification, an employee may be moved to a position within a relevant job family that does not require certification/licensure, if and when such position is available.
• Knowledge of applicable laws and statutes (state, local or federal) for positions focusing on Workers' Compensation or automobile medical ("auto") bills a plus
• Knowledge of general office operations and/or experience with standard medical insurance claim forms
• Good Communication (verbal, written and listening)
• teamwork, negotiation, and organizational skills.
• Ability to process verbal and written instructions.
• Display professionalism by having a positive demeanor, proper telephone etiquette and use of proper language and tone in a business professional environment.
• Ability to: Commit to providing a level of customer service within established standards.
• Provide attention to detail to ensure accuracy including mathematical calculations.
• Identify issues and determine appropriate course of action for resolution.
• Organize workload to meet deadlines and participate in department/team meetings.
• Adjust/alter workflow to meet deadlines in a fast-paced environment.
• Work independently and handle confidential information.
• Ability to use software and hardware related to job responsibilities, including MS Word and MS Excel spreadsheets and database software.
• Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier, and telephone.

Compensation

The salary range for this position is $20.23 per hour. Specific offers take into account a candidate’s education, experience and skills, as well as the candidate’s work location and internal equity. This position is also eligible for health insurance, 401k and bonus opportunity.

Benefits

• Medical, dental and vision coverage with low deductible & copay
• Life insurance
• Short and long-term disability
• Paid Parental Leave
• 401(k) + match
• Employee Stock Purchase Plan
• Tuition reimbursement
• Flexible Spending Account
• Employee Assistance Program
• Sick time benefits - for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits
• EEO STATEMENT

EEO STATEMENT

Claritev is an Equal Opportunity Employer and complies with all applicable laws and regulations. Qualified applicants will receive consideration for employment without regard to age, race, color, religion, gender, sexual orientation, gender identity, national origin, disability or protected veteran status.