1+ years of experience conducting research to resolve issues within the healthcare field
Strong computer skills, including proficiency in MS Word and Excel
Excellent oral and written communication skills
Requirements:
Independently resolve suspended claims using the resolution screens in accordance with operational procedures and process recoupments.
Review and analyze claims and follow up on the status of claims and reimbursement.
Ensure accuracy and consistency in claims processing.
Interpret and apply policy and reimbursement rules to support provider inquiries.
Job description
Our Client, a Leading Provider of Healthcare Delivery Systems and Solutions company, is looking for a Claims Resolution Representative for their Remote location.
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.
Requirements:
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
