Acentra Health-posted 3 months ago
$14 - $20/Yr
Full-time
Cheyenne, WY

Acentra Health is looking for a Claims Resolution Representative to join our growing team. The Claims Resolution Representative plays a vital role in ensuring accuracy and adherence to the applicable state's Department of Health 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.

  • 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 (paper or electronic) and process them according to Wyoming Department of Health policies and procedures
  • Possess an unwavering commitment to customer service and operational excellence
  • Perform manual pricing and audit checks to ensure compliance with Wyoming 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 between CNSI and the state
  • 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
  • High School Diploma or GED
  • Be available to work from 8:00 AM to 5:00 PM Mountain Time on all State business days, Monday through Friday (excluding State holidays)
  • Experience conducting research to resolve issues within the healthcare field
  • 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
  • Dependable in production
  • Demonstrate leadership through consistent on-site (or offsite for remote) attendance
  • Create and maintain a positive atmosphere, demonstrating leadership qualities
  • Encourage teamwork throughout the entire account
  • Knowledgeable in claims review and analysis
  • Familiarity with Medicare and Medicaid
  • Comprehensive health plans
  • Paid time off
  • Retirement savings
  • Corporate wellness
  • Educational assistance
  • Corporate discounts
© 2024 Teal Labs, Inc
Privacy PolicyTerms of Service