SUMMARY

Under the general direction of the Claims Compliance Manager, The Director of Claims Operations and/or Director of Operations, this position will be responsible for processing/adjusting and handling any claims that are incomplete or escalated for validation. This person will also be responsible for analyzing claims and making decisions about their validity. The position will be a communicator to internal and external business partners and a problem solver/agent for change to provide continuous improvements.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Processes/adjusts escalated claims, assesses the reason for the escalation, and provides resolution in priority order as directed by the leadership
• Searches for and links invoices and contracts to claims as needed
• Uses systems, reports, and Standard Operating Procedures to work assigned claim steps and gather supporting claims information
• Corrects and resolves claims ‘clean passed’ in error
• Researches validation issues and recommends appropriate solutions
• Reviews claims dashboard for actionable items on a frequent basis
• Meets or exceeds client and customer goals and requirements
• Makes the final decision on claims validity for escalated claims
• Contacts management team for information as needed
• Proactively manages client and customer target dates to ensure claims are processed in a timely manner
• Communicates with clients and customers on a regular basis and provides value add solutions
• Escalates appropriately to the Supervisor/Manager when needed to get information or handle complex client and customer situations
• Understands types of escalations and uses problem solving and analytical skills to resolve them so they do not repeat
• Works to decrease defects and achieve automation (aka Ready to Clear) targets by keeping Policies and Procedures updated
• Monitors specific escalations data to determine the root cause of an escalation, where it originated and why it occurred
• Discusses defect issues with Terms and Conditions, Configuration and management teams and works with them to address the root cause
• Recognizes and provides solutions for operational obstacles that delay work completion on claims issues
• Other duties as assigned

SUPERVISORY RESPONSIBILITIES

Position does not have any supervisory responsibilities.

QUALIFICATIONS: 

• Four years claims experience preferred to include adjustments of claims
• EZCAP experience a plus
• Relationship management experience preferred
• Accepts accountability for job performance; proactively informs others when he/she encounters problems that may limit his/her ability to meet expectations
• Accepts change as a normal part of doing business, maintains a positive attitude and exhibiting constructive work behaviors during periods of transition
• Meets work and attendance expectation; informs others in advance when commitments cannot be fulfilled
• Actively supports organizational goals and values; aligns actions around organizational goals; gives priority to organizational needs and concerns when making decisions
• Takes a reasoned logical approach in making judgments and decisions, carefully reviews available facts and information before reaching any conclusions
• Identifies and gathers relevant information, consults the right people and asks the right questions in a given situation
• Demonstrates disciplined thinking that is clear, unbiased, analytical and informed by evidence
• Effectively communicate with others.

EDUCATION and/or EXPERIENCE

Minimum high school diploma or GED is required.

• Coding certification is preferred.
• Minimum of four (4) years of experience in healthcare claims processing, including either adjustments, provider dispute resolution and/or auditing
• HCPCS, CPT, ICD10 coding experience is required.
• Knowledge of Medicare, Medicaid, or commercial insurance is needed. Knowledge of various payment and pricing methodologies.
• The ability to deal with confidential information is essential.
• Excellent verbal and written communication skills, including the ability to effectively communicate with internal and external customers.
• Excellent computer proficiency in MS Office products including expertise in MS Excel (creating spreadsheets and using advanced formulas) and PowerPoint.
• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service.
• Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practices.
• Understands and is able to apply insurance laws and regulations.

LANGUAGE SKILLS 

Ability to read and comprehend simple instructions, correspondence, contracts, and memos. Ability to effectively present information in one-on-one and/or small group situations to upper management, and other employees of the organization.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; reach with hands and arms; stoop, kneel, crouch, or crawl; and talk or hear.  The employee must occasionally lift and/or move up to 10 pounds.  Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Moderate noise (Examples: business office with computers and printers, light traffic).

EMPLOYMENT STATUS

Non-Exempt Position

ADDITIONAL INFORMATION

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.