Provider Claims Pricing Specialist

Employer Direct Healthcare•Dallas, TX

35d

About The Position

Our Reimbursement Specialists are a central points of contact for our provider network. The primary responsibility of the role is to deliver effective, accurate payment and communication to our providers. The day-to-day responsibilities of our Reimbursement Specialists include payment processing, researching, accurate billing/payment disbursement, and ensuring payment data accuracy and integrity. The desired candidate is articulate, empathetic, pragmatic, self-starting and ambitious. In addition, our Reimbursement Specialists are horizontal thinkers, analytical, organized and detail oriented.

Requirements

Minimum Bachelor's degree in healthcare, business, marketing or related field; or HS Diploma (or GED) and 4 years' applicable experience
Minimum 2 years of experience in previous claims, health insurance or healthcare practice
Knowledge of medical coding systems (i.e., CPT, ICD-9/10, revenue codes) preferred
Knowledge of commonly used medical data resources preferred
Knowledge of payor contracts and interpretation
Knowledge of general office operations and/or experience with standard medical insurance claim forms preferred
Strong communication (verbal, written and listening), teamwork, negotiation and organizational skills
Ability to commit to providing a level of customer service within established standards
Ability to provide attention to detail to ensure accuracy including mathematical calculations
Ability to organize workload to meet deadlines and participate in department/team meetings
Ability to analyze data and arrive at a logical conclusion
Ability to identify issues and determine appropriate course of action for resolution
Ability to display professionalism by having a positive demeanor, proper telephone etiquette and use of proper language and tone
Ability to use software and hardware related to job responsibilities, including MS Office Suite and database software
Ability to work with accuracy in a fast-paced environment
Ability to work independently and handle PHI and confidential information
Ability to process detailed verbal and written instructions
Individual in this position must be able to work in a traditional 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

Responsibilities

Processes provider payments in accordance with company policies and procedures.
Serves as primary contact to Finance Department regarding payment, determinations and payment processing activities.
Assist in the final determination on claim disposition and payment determination.
Serves as liaison to internal departments regarding provider related inquiries on claims related content.
Processes adjustments or provider disputes providing timely follow-up.
Coordinates research and responds to system inquiries from providers regarding payment, reimbursement determination, provider contact information and claims billing procedures.
Communicates with supervisor on a daily and/or weekly basis regarding any outstanding claims issues related to system, authorizations, reimbursement/payment errors or internal approvals.
Works with provider contracting staff when new/modified reimbursement contracts are needed
Performs pre-adjudication claims reviews to ensure proper terms and schedules were used.
Initiate necessary actions regarding pending claims or payment documentation.
Follow up on open items reports to timely and accurate resolution.
Respond proactively to provider issues and concerns and give feedback to management.
Provide feedback to the manager regarding proper claims billing procedures in accordance with company policy and procedures.
Assist in training new Payment Specialists.
Initiate change requests to resolve system issues impacting claims/payment processing or issue resolution
Runs and analyzes daily activity reports.
Analyze, develop and deliver claims resolutions quickly and accurately according to company policies and procedures.