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Claims Resolution Representative

Metasys Technologies

  • McLean, VA
  • 30+ days ago
  • Remote
  • $18.62–$23.27 Per Hour
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Skills

  • Adjudicationunmatched
  • Analysis Skillsunmatched
  • Claims Processingunmatched
  • Communication Skillsunmatched
  • Computer Skillsunmatched
  • Customer Satisfactionunmatched
  • Customer Service Operationsunmatched
  • Demographicsunmatched
  • Establish Prioritiesunmatched
  • HIPAA (Health Insurance Portability and Accountability Act)unmatched
  • Healthcareunmatched
  • High School Diplomaunmatched
  • Leadershipunmatched
  • Maintain Complianceunmatched
  • Microsoft Excelunmatched
  • Microsoft Wordunmatched
  • Operations Processesunmatched
  • Presentation/Verbal Skillsunmatched
  • Pricingunmatched
  • Privacy Controlsunmatched
  • Problem Solving Skillsunmatched
  • Process Capabilityunmatched
  • Reimbursementunmatched
  • Research Skillsunmatched
  • Team Playerunmatched
  • Time Managementunmatched
  • Writing Skillsunmatched

Description

Claims Resolution Representative
Remote Role
Duration: 6 months (Possible Contract to Perm)

Job Summary:
The Claims Resolution Representative plays a vital role in ensuring accuracy and adherence to the applicable 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.
*This position is remote within the United States, but applicants can expect to work Eastern Time regular business hours with some flexibility.

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 (electronic) and process them according to policies and procedures.
  • Possess an unwavering commitment to customer service and operational excellence.
  • Perform manual pricing and audit checks to ensure compliance with 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.
  • 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.
Required Qualifications
  • High School Diploma or GED
  • 1+ years of experience conducting research to resolve issues within the healthcare field
Preferred Qualifications
  • 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
  • Create and maintain a positive atmosphere, demonstrating leadership qualities
  • Knowledgeable in claims review and analysis

Numbers & Facts

LocationMcLean, VA (
Remote
)
IndustryComputer/IT Services
Salary$18.62–$23.27 Per Hour
Company Size100 to 499 employees
Year Founded2000
Websitehttp://metasysinc.com/

About Company

With over 15 years of experience, Metasys Technologies (MTI) provides consultants with rewarding career opportunities in a multitude of organizations.

Rated by The Atlanta Business Chronicle as one of the best places to work, MTI provides our consultants with opportunities for growth and recognition. MTI has a nationwide network of clients including Fortune 50 companies and numerous medium to small sized businesses.

We offer opportunities in I.T. Professional Services, Finance & Accounting, and Business Professional Services.

Our tools and consultant care program help you with the interview process and provide you with continuous guidance and insight.

If you are a candidate looking for career growth or change, we can help you find a career that matches your aspirations.

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