Job title: Claims Resolution Representative
Position: 6 months contract to hire
100% remote
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
Pay: $19.00 - $22.00 per hour
Work Location: Remote
