Claims Resolution Representative

Acentra Health • Cheyenne, WY

156d • $14 - $20

About The Position

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.

Requirements

• 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)

Nice To Haves

• 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

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 (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

Benefits

• Comprehensive health plans
• Paid time off
• Retirement savings
• Corporate wellness
• Educational assistance
• Corporate discounts

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED