Claims Resolution Specialist

Claritev•New York, NY

3d•Onsite

About The Position

This position is responsible for contacting healthcare providers to discuss negotiations for a specific dollar range of eligible claims/bills prior to payment, in order to achieve maximum discounts and savings on behalf of payor/client.

Requirements

Minimum high school diploma or GED
Minimum 6 months experience in the health care industry (provider billing, medical coding, provider collections, insurance, or managed care); 1 year preferred.
State licensure certification, including NY Health and/or P&C State Adjustor license, may be required. If hired without certification, certification must be obtained, and maintained thereafter, within six months of notification. If the required state licensure certification(s) are not obtained or renewed within six months of notification, an employee may be moved to a position within a relevant job family that does not require certification/licensure, if and when such position is available. When an alternate position is unavailable, other employment actions may be implemented consistent with Claritev practice and policy.
Knowledge of applicable laws and statutes (state, local or federal) for positions focusing on Workers' Compensation or automobile medical ("auto") bills a plus
Knowledge of general office operations and/or experience with standard medical insurance claim forms
Good Communication (verbal, written and listening) teamwork, negotiation, and organizational skills.
Ability to process verbal and written instructions.
Display professionalism by having a positive demeanor, proper telephone etiquette and use of proper language and tone in a business professional environment.
Ability to: Commit to providing a level of customer service within established standards.
Provide attention to detail to ensure accuracy including mathematical calculations.
Identify issues and determine appropriate course of action for resolution.
Organize workload to meet deadlines and participate in department/team meetings.
Adjust/alter workflow to meet deadlines in a fast-paced environment.
Work independently and handle confidential information.
Ability to use software and hardware related to job responsibilities, including MS Word and MS Excel spreadsheets and database software.
Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier, and telephone.

Nice To Haves

Knowledge of applicable laws and statutes (state, local or federal) for positions focusing on Workers' Compensation or automobile medical ("auto") bills a plus

Responsibilities

Manage a high volume of healthcare claims thoroughly to maximize savings opportunities on each claim within the established department production standards and individual goals by contacting provider on all assigned claims and presenting a proposal while maintaining high quality standards.
Perform provider research to provide support for desired savings.
Address counteroffers received and present proposal for resolution while adhering to client guidelines and policy and procedures.
Seek opportunities to achieve savings with previously challenging/unsuccessful providers.
Seek opportunities to establish ongoing global or concurrent agreements for future claims.
Update provider data base for reference and claims processing on subsequent claims.
Initiate provider telephone calls as often required with respect to proposals, overcome objections and apply effective telephone negotiation skills to reach successful resolution on negotiated claims.
Up to 40% of time will be on phone with providers.
Provider education to providers online provider portal services available for proposal review and approval.
Meet and maintain established departmental performance metrics.
Handle post claim closure service inquires, including payment status and defending original negotiation terms.
May require ACD phone responsibilities and tracking outcomes.
Collaborate, coordinate, and communicate across disciplines and departments.
Ensure compliance with HIPAA protocol.
Demonstrate Company's Core Competencies and values held within.
Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.
The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned, as necessary.

Benefits

Medical, dental and vision coverage with low deductible & copay
Life insurance
Short and long-term disability
Paid Parental Leave
401(k) + match
Employee Stock Purchase Plan
Generous Paid Time Off – accrued based on years of service
WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service
10 paid company holidays
Tuition reimbursement
Flexible Spending Account
Employee Assistance Program
Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits