Claims Resolution Representative

Claims Resolution Representative:
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