Claims Resolution Representative

Acentra Health, LLC•Cheyenne, WY

6d•Onsite

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

Strong computer skills, including proficiency in Microsoft Word and Excel, with the ability to navigate multiple claims and eligibility systems simultaneously
Outstanding customer service skills with the ability to interact professionally, tactfully, and empathetically while maintaining appropriate boundaries
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
Demonstrate professionalism and dependability through consistent attendance
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 Acentra 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.
May make outbound calls as related to workload.
Other duties as assigned.
Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.