Job 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:
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.
- High School Diploma or GED
- 1+ years of experience conducting research to resolve issues within the healthcare field
- 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
| Location | McLean, VA (Remote) |
| Industry | Computer/IT Services |
| Salary | $18.62–$23.27 Per Hour |
| Company Size | 100 to 499 employees |
| Year Founded | 2000 |
| Website | http://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.
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
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