Claims Resolution Specialist

About Our Client

The organization operates within the healthcare cost management industry. It addresses the challenge of controlling rising healthcare expenses by negotiating claims to maximize discounts and savings for payors and clients. The team focuses on leveraging technology, data, and innovation to transform healthcare cost structures and improve efficiency.

About the Opportunity

The Claims Resolution Specialist I is responsible for negotiating healthcare claims to secure maximum savings before payment. This role impacts the organization by directly reducing healthcare costs through effective provider negotiations, contributing to cost containment efforts and supporting client financial objectives.

Responsibilities

• Manage high volume of healthcare claims to maximize savings within established standards and goals.
• Conduct provider research to support savings proposals.
• Address counteroffers and negotiate resolutions in line with client policies.
• Identify opportunities with challenging providers and establish ongoing agreements.
• Update provider database for future claim processing.
• Initiate telephone calls to providers, applying negotiation skills to reach resolutions.
• Educate providers on portal services for proposal review and approval.
• Meet and maintain departmental performance metrics.
• Handle post-claim service inquiries including payment status and negotiation defense.
• Perform ACD phone responsibilities and track outcomes as needed.
• Collaborate and communicate across departments.
• Ensure compliance with HIPAA protocols.
• Adhere to core competencies and organizational values.
• Manage exposure to sensitive PHI data, recognizing the role as high risk.

Requirements

• A high school diploma or GED minimum.
• At least six months of experience in healthcare industry roles such as provider billing, medical coding, collections, insurance, or managed care.
• State licensure certification (e.g., NY Health or P&C State Adjustor license) may be required; must be obtained within six months if hired without it.
• Knowledge of applicable laws and statutes relevant to workers' compensation or automobile medical bills is a plus.
• Familiarity with standard medical insurance claim forms and general office operations.
• Strong communication, teamwork, negotiation, and organizational skills.
• Ability to follow verbal and written instructions with professionalism.
• Attention to detail and accuracy in calculations.
• Problem-solving skills to identify and resolve issues.
• Ability to manage workload, meet deadlines, and adapt in a fast-paced setting.
• Capability to work independently and handle confidential information.
• Proficiency with job-related software, including MS Word and Excel.
• Ability to work in a standard office environment requiring prolonged sitting.

Pay Range and Compensation Package

The salary range for this position is $20.23 per hour. Compensation offers consider education, experience, skills, work location, and internal equity. Eligibility for health insurance, 401(k) plan, and bonus opportunities.

Equal Opportunity Statement

Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.